Clinical classification of recurrent laryngeal nerve palsy

Background

The application of intraoperative neurophysiological monitoring (IONM) has been accepted to avoid injury of a recurrent laryngeal nerve (RLN). Loss of the neuromonitoring signal indicates nerve injury and is subdivided into segmental type and global type nerve paralysis. This study aimed to determine the course of vocal cord function recovery after definitive loss of signal (LOS) types.

Methods

This retrospective study included 1,442 patients (with 2,752 nerves at risk) who had thyroidectomies between January 2018 and December 2021. Preoperative and postoperative vocal cord functions were evaluated by laryngoscopic examination.

Results

LOS occurred in 168 of 1,442 (11.7%) patients and 171 of 2,748 (6.2%) nerves at risk during surgery. Of LOS nerves of benign tumors, 74.2% showed global type. In cancer cases, segmental paralysis was more common, accounting for 51.3% of LOS nerves. Of nerves with segmental LOS in cancer patients, 55.3% needed partial layer resection for RLN invasion. Intraoperative recovery was seen in 9 of 62 nerves (14.5%) with segmental LOS and 32 of 109 (29.4%) nerves with global type LOS. The vocal cord palsy rate on postoperative days (PODs) 2-3 was lower after global type nerve paralysis (63.6%) than after segmental loss (84.9%). At 6 months postoperatively, the rate of vocal cord paralysis in benign tumors was not significantly different between segmental type and global type (P=0.586). However, cancer patients with segmental LOS significantly more often had vocal cord dysfunction than those with global LOS at 6 months postoperatively (rate of nerve palsy: segmental 40.0% vs. global 3.4%) (P<0.001).

Conclusions

The intraoperative recovery rate and early nerve recovery rate are significantly higher for patients with global LOS than for patients with segmental LOS. Cancer patients with segmental LOS significantly more often had vocal cord dysfunction than those with global LOS at 6 months postoperatively.

Role of Surgery in Patients with Stage IE Primary Thyroid MALT Lymphoma Staged by a Modified Classification System: The Tokyo Classification

PURPOSES

To establish the appropriate staging system and assess the role of curative thyroidectomy alone (Surgery) vs. involved-site radiation therapy after open biopsy (OB-ISRT) in stage IE mucosa-associated lymphoid tissue (MALT) lymphoma.

METHODS

We examined the Tokyo Classification as a modified classification. This retrospective cohort study included 256 patients with thyroid MALT lymphoma; 137 underwent standard therapy (i.e., OB-ISRT) and were enrolled for the Tokyo classification. Sixty stage IE patients with the same diagnosis were examined to compare Surgery with OB-ISRT.

RESULTS

Overall survival (p = 0.0092) and relapse-free survival (0.00113) were significantly better in stage IE vs. stage IIE under the Tokyo classification. No OB-ISRT and Surgery patients died, but three OB-ISRT patients relapsed. The incidence of permanent complications was 28% in OB-ISRT (mainly dry mouth) and 0% in Surgery (p = 0.027). The number of painkiller prescription days was significantly greater in OB-ISRT (p < 0.001). During follow-up, the rate of the new appearance/change of the low-density area in the thyroid gland was significantly higher in OB-ISRT (p = 0.031).

CONCLUSIONS

The Tokyo classification allows an appropriate discrimination between stages IE and IIE MALT lymphoma. Surgery can provide a good prognosis in stage IE cases; it also avoids complications, shortens painful periods during treatment, and simplifies ultrasound follow-up.

Successful dose escalation of lenvatinib for thyroid cancer after disease progression

PURPOSE

Lenvatinib is started at a standard dose, continuing with dose reduction and interruption, balancing between efficacy and adverse events (AEs). Because few drugs are available for thyroid cancer, efforts for continuing treatment with one agent, such as "dose escalation (DE)", are made. The dose is increased, aiming to regain the anti-tumor effect after dose reduction. The effects of lenvatinib DE in differentiated thyroid carcinoma (DTC) patients are reported.

PATIENTS AND METHODS

The efficacy of lenvatinib DE in DTC patients using the serum thyroglobulin (Tg) level and management of AEs was investigated.

RESULTS

A total of 70 DE episodes in 33 patients were investigated. The median increased dose was 2.0 (1.0-14.0) mg, increased from 8.6 (2-16) mg to 10.1 (6-24) mg. The serum Tg level decreased in 53 DE episodes. Though the serum Tg level in 17 DE episodes was not decreased, the Tg rate of increase was decreased in 7 of these DE episodes using the Tg-doubling rate. Overall, clinical benefit was seen in 60 (86%) DE episodes. AEs that could not be controlled after DEs were seen in only 16% of cases. No intolerable AEs were observed in patients who received more drug holidays at the time of DEs compared to two times before the DEs.

CONCLUSION

DE may become one of the standard treatment strategies after disease progression if AEs are well managed. Drug holidays may be a key for successfully controlling AEs with DE. DE can be useful for controlling progressive disease with increasing Tg levels.

Response to neoadjuvant paclitaxel predicts survival in anaplastic thyroid carcinoma

The clinical utilities of paclitaxel in anaplastic thyroid carcinoma (ATC) have been reported. The current study investigated the outcomes in ATC patients treated by paclitaxel as neoadjuvant setting. Furthermore, the prognostic factor for overall survival (OS) and predictive marker for response to paclitaxel were investigated. Records of ATC patients treated by paclitaxel as neoadjuvant setting in our hospital were reviewed. The median OS for the patients with (n = 43) and without (n = 23) resection were 14.7 (95% CI, 11.0-21.7) and 4.2 (95% CI, 3.0-5.4) months, respectively (p < 0.001). Univariate analysis identified the factors of stage (p = 0.028), prognostic index (PI) ≥2 (p < 0.001), response to paclitaxel (p = 0.007), resection (p < 0.001), and radiotherapy (p < 0.001) to be associated with OS, and multivariate analysis revealed that the factors of PI ≥2 [hazard ratio (HR), 2.406 (95% CI, 1.096-5.281), p = 0.029], response to paclitaxel [HR, 0.423 (95% CI, 0.193-0.930), p = 0.032], resection [HR, 0.316 (95% CI, 0.129-0.773), p = 0.012], and radiotherapy [HR, 0.229 (95% CI, 0.100-0.526), p < 0.001] were independent prognostic factors of OS. There were no significant predictive factors for response to paclitaxel in baseline characteristics. PI ≥2, response to paclitaxel, resection, and radiotherapy were independent prognostic factors in ATC patients treated with paclitaxel as neoadjuvant setting. It is important to investigate predictor for response to paclitaxel for improving resectability and prognosis in ATC.

Preoperative inflammatory markers for predicting parathyroid carcinoma

OBJECTIVE

Parathyroid carcinoma is a rare tumor among parathyroid tumors. Aspiration cytology and needle biopsy are generally not recommended for diagnostic purposes because they cause dissemination. Therefore, it is commonly diagnosed by postoperative histopathological examination. In this study, we investigated whether preoperative inflammatory markers can be used as predictors of cancer in patients with primary hyperparathyroidism.

DESIGN

This was a retrospective study.

METHODS

Thirty-six cases of parathyroid carcinoma and 50 cases of parathyroid adenoma (PA) operated with the diagnosis of primary hyperparathyroidism and confirmed histopathologically at Ito Hospital were included in this study. Preoperative clinical characteristics and inflammatory markers (neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio (LMR)) were compared and their values in preoperative prediction were evaluated and analyzed.

RESULTS

Preoperative intact-parathyroid hormone (P = 0.0003), serum calcium (P = 0.0048), and tumor diameter (P = 0.0002) were significantly higher in parathyroid carcinoma than in PA. LMR showed a significant decrease in parathyroid carcinoma (P = 0.0062). In multivariate analysis, LMR and tumor length diameter were independent predictors. In the receiver operating characteristics analysis, the cut-off values for LMR and tumor length diameter were 4.85 and 28.0 mm, respectively, for parathyroid cancer prediction. When the two extracted factors were stratified by the number of factors held, the predictive ability improved as the number of factors increased.

CONCLUSION

In the preoperative evaluation, a combination of tumor length diameter of more than 28 mm and LMR of less than 4.85 was considered to have a high probability of cancer.

Clinical course and outcome of differentiated thyroid cancer patients with pregnancy after diagnosis of distant metastasis

PURPOSE

There is no sufficient data about the clinical course and outcome in thyroid cancer patients who become pregnant after diagnosis of distant metastasis (DM). The current study was conducted to collect information regarding the clinical and reproductive characteristics, and outcomes in thyroid cancer patients who became pregnant after being diagnosed with DM.

METHODS

Records of 125 differentiated thyroid cancer (DTC) patients with age ≤45 years at DM diagnosis who had visited Ito Hospital from January 2005 to June 2021 were retrospectively reviewed. Among those 125 patients, 28 who became pregnant after DM diagnosis were classified as pregnancy group, and the remained 97 patients were classified as comparator group.

RESULTS

In pregnancy group, the median age at malignancy diagnosis, DM diagnosis, and first pregnancy after DM diagnosis was 25 years (range, 4-41 years), 27 years (range, 11-41 years), and 32 years (range, 25-45 years), respectively. Fifty-five pregnancies and 40 live births were reported. Other pregnancy outcomes were miscarriage (n = 14) and induced abortion (n = 1). The 10-year progression-free survival (PFS) rates of pregnant and comparator group were 92.1% and 74.4%, respectively (p = 0.018). The multivariate analysis showed that multiple ¹³¹I treatment was independent negative prognostic factor for PFS (p = 0.046).

CONCLUSIONS

DTC patients with age ≤45 years at DM diagnosis had good survival even though they became pregnant. Our results add to the information required for counseling thyroid cancer patients who have concerns about their fertility in the future.

Encapsulated Angioinvasive Follicular Thyroid Carcinoma: Prognostic Impact of the Extent of Vascular Invasion

BACKGROUND

Previous studies have reported an association between four or more foci of vascular invasion (VI) and thyroid cancer prognosis, while the current study aimed to investigate the association between extent of VI and outcome of encapsulated angioinvasive follicular thyroid carcinoma (FTC).

METHODS

The records of 303 patients with encapsulated angioinvasive FTC confirmed by surgical specimens at Ito Hospital from January 2005 to December 2014 were retrospectively reviewed. Thirteen patients had distant metastasis at diagnosis and were classified as M1.

RESULTS

Among the 290 patients with M0 encapsulated angioinvasive FTC, the 10-year disease-free survival (DFS) rate was 85.6%. Those with a VI of 1 (n = 131) or ≥ 2 (n = 159) had a 10-year DFS rate of 94.9% and 77.9% (p < 0.001), respectively, and those with a VI of 1-3 (n = 211) or ≥ 4 (n = 79) had a 10-year DFS rate of 86.3% and 83.3% (p = 0.311), respectively. Multivariate analysis identified age ≥ 55 years (p = 0.031) and VI ≥ 2 (p = 0.002) as independent negative prognostic factors for DFS. Patients with M0 encapsulated angioinvasive FTC aged ≥ 55 years and VI ≥ 2 had significantly poorer prognosis and a 10-year DFS rate of 66.4% (p < 0.001).

CONCLUSIONS

Patients with encapsulated angioinvasive FTC who had two or more foci of VI, especially patients aged ≥ 55 years, should be carefully followed-up.

Cutoff Age Between Pediatric and Adult Thyroid Differentiated Cancer: Is 18 Years Old Appropriate?

Background: The characteristics of pediatric differentiated thyroid cancer (DTC) are substantially different from those of adult DTC. This study investigated whether the cutoff age of 18 years, as recommended by the American Thyroid Association (ATA) management guidelines for pediatric DTC, is appropriate based on clinical characteristics and outcomes. Methods: The medical records of 288 patients aged <21 years with DTC, who underwent initial surgery between 1979 and 2014, were retrospectively reviewed. Disease-free survival (DFS) rates and distant metastasis-free survival (DMFS) rates were calculated using the Kaplan-Meier method. As per the International Incidence of Childhood Cancer Report and the ATA management guidelines, cutoff ages of 14 and 18 years were analyzed in this study. Results: The age distributions of the subjects were as follows: 53 patients were aged <15 years (18.4%), 118 patients were aged 15-18 years (41%), and 117 patients were aged 19-20 years (40.6%). The DMFS rates were significantly different between the two cutoff ages. The DMFS was also significantly different between patients aged >15 years and patients aged 15-18 years; however, no significant difference was observed between patients aged 15-18 and 19-20 years. Multivariate analyses showed that clinically apparent lymph node metastasis (cN1) and gross extrathyroidal extension were significant factors related to DFS and DMFS. Although age as a continuous variant was not a significant factor related to either DFS or DMFS, when the cutoff age was set as 14 years rather than 18 years, differences in patient characteristics related to DMFS and DFS stood out. Conclusions: This study found that age was not significantly related to clinical outcome. However, in the younger patient group, more patients had factors that related to DFS and DMFS. Due to the indolent biological behavior of DTC, age at presentation or thyroidectomy does not always represent the age at occurrence, but patients aged <15 years had distinct clinical manifestations. Age <15 years rather than <19 years may therefore be a more suitable cutoff age in pediatric DTC.

Impact of lenvatinib on renal function: long-term analysis of differentiated thyroid cancer patients

Background

Because lenvatinib is well known to induce proteinuria by blocking the vascular endothelial growth factor (VEGF) pathway, renal function is a concern with long-term administration of lenvatinib. The long-term effects of lenvatinib on renal function in patients with advanced differentiated thyroid carcinoma (DTC) were analyzed.

Method

This study involved 40 DTC patients who continued lenvatinib therapy for ≥6 months. Estimated glomerular filtration rate (eGFR) was calculated as an indicator of renal function. The temporal course of eGFR, effects of baseline eGFR on eGFR changes, and factors affecting renal impairment were investigated.

Results

The overall cohort showed sustainable decreases in eGFR, with decreased values of 11.4, 18.3, and 21.0 mL/min/1.73 m² at 24, 36, and 48 months after starting treatment, respectively. No differences in eGFR decrease every 6 months were seen for three groups classified by baseline eGFR ≥90 mL/min/1.73 m² (n = 6), < 90 but ≥60 mL/min/1.73 m² (n = 26), or < 60 but ≥45 mL/min/1.73 m² (n = 8). Grade 3 proteinuria was associated with declines in eGFR (p = 0.0283). Long observation period was also associated with decreases in eGFR (p = 0.0115), indicating that eGFR may decrease in a time-dependent manner.

Conclusion

Lenvatinib can induce declines in eGFR, particularly with treatment duration > 2 years, regardless of baseline eGFR. Proteinuria is a risk factor for declines in eGFR. Patients who start lenvatinib with better renal function show a renal reserve capacity, prolonging clinical outcomes. Decision-making protocols must balance the benefits of lenvatinib continuation with acceptable risks of harm.

Risk stratification in differentiated thyroid cancer with RAI-avid lung metastases

OBJECTIVE

Radioactive iodine (RAI) therapy is effective for differentiated thyroid cancer (DTC) patients with lung metastasis. However, some patients have a poor prognosis despite the RAI accumulation. The utility of inflammatory biomarkers, including neutrophil-to-lymphocyte ratio (NLR), has been reported as a prognostic factor for many carcinomas. This study aimed to investigate the risk factors related to DTC patient survival with RAI-avid lung metastasis and to attempt risk stratification.

DESIGN AND METHODS

This retrospective study included 123 patients with RAI-accumulating lung metastatic DTC. The cause-specific survival (CSS) rate from the time of detection of lung metastasis was tested using the Kaplan-Meier log-rank test, and the multivariate analysis was calculated using the Cox proportional hazards model. NLR was retrospectively calculated using the blood sample collected before initial RAI treatment. The NLR cutoff value was 2.6 on the ROC curve.

RESULTS

Age ≥ 55 years at the time of operative treatment, follicular carcinoma, lung metastasis tumor ≥ 10 mm in diameter, age ≥ 55 years at the time of detection of lung metastasis, age ≥ 55 years at the time of RAI treatment, and NLR ≥ 2.6 at the initial RAI treatment were predictive of decreased CSS. Multivariate analysis identified that the independent prognostic factors were lung metastatic tumor ≥ 10 mm in diameter and NLR ≥ 2.6. Patients in the high-risk group with both factors had significantly lower CSS rates than those in the low- and intermediate-risk groups with one or none of these factors.

CONCLUSIONS

The high-risk group patients had significantly poorer survival, and these patients could be considered as future candidates for tyrosine kinase inhibitor therapy.

The Time Series Behavior of Neutrophil-to-Lymphocyte Ratio in Thyroid Cancer Patients on Tyrosine Kinase Inhibitor Therapy

INTRODUCTION

The neutrophil-to-lymphocyte ratio (NLR) reveals the balance of immune system is and associated with survival in various type of cancers. Tyrosine kinase inhibitors (TKI) improve patient survival with progressing thyroid cancer and are said to have less side effects, and are considered good palliation.

OBJECTIVE

This study evaluated the time series behavior of NLR in advanced thyroid carcinoma patients on TKI therapy and examined what percentage of patients received TKIs in the last month of life.

METHODS

We retrospectively reviewed medical records on 72 patients with advanced thyroid carcinoma treated with TKIs between May 2015 and October 2018. All patients had progressive disease and/or uncontrolled distant metastasis. Fifty-two patients had differentiated thyroid carcinoma (DTC), 19 patients had anaplastic carcinoma (ATC), and 1 had squamous cell carcinoma. NLR was calculated as the absolute neutrophil count divided by the absolute lymphocyte count. Median follow-up time in DTC and ATC patients was 12.3 months (range 0.9-40.4) and 2.7 months (range 0.6-14.3), respectively.

RESULTS

In DTC patients, median NLR at initial treatment, at initiation of TKI, and for 20 patients who died at the time of death was 2.25 (range, 0.89-9.78), 3.55 (range, 0.86-28.3), and 11.78 (range, 0.98-98.0), respectively. In ATC patients, median NLR at initial treatment, at initiation of TKI, and for 16 patients who died at the time of death was 2.96 (range, 1.12-9.0), 11.43 (range, 2.32-95.0), and 16.9 (range, 3.45-95.0), respectively. NLR >10 at TKI initiation was significantly associated with shorter overall survival compared with NLR <4 and NLR 4-10 (p < 0.0001) in DTC patients. Among 46 dead patients, 32 patients (68.1%) received TKIs treatment in the last month of life (85% DTC patients and 61.5% ATC patients). In receiver operating characteristic curve analysis, cutoffs for DTC and ATC were 11.43 (p = 0.0488, area under the ROC curve 0.941) and 31.67 (p = 0.0034, area under the ROC curve 0.831) in patients who survived ≤6 weeks and >6 weeks, respectively.

CONCLUSION

A substantial percentage of patients received TKIs in the last month of life. The NLR increased according to tumor progression and predicted survival after TKI initiation. We might refer the patients with NLR >11.43 in DTC and those with NLR >31.67 in ATC to a hospice/palliative care program.

Outcomes for Minimally Invasive Follicular Thyroid Carcinoma in Relation to the Change in Age Stratification in the AJCC 8th Edition

BACKGROUND

Completion total thyroidectomy with radioactive iodine (RAI) therapy is not uniformly recommended for minimally invasive follicular thyroid carcinomas (MI-FTCs) without distant metastasis, but may be considered for cases with a risk factor of recurrence, such as age ≥ 45 years.

OBJECTIVE

The present study aimed to investigate the outcomes for patients with MI-FTC using a stratification age of 55 years.

METHODS

The records of 478 patients with MI-FTC confirmed by surgical specimens at Ito Hospital from January 2005 to December 2014 were retrospectively reviewed. Twenty patients had distant metastasis at diagnosis and were subsequently classified as M1.

RESULTS

Among the 478 patients with MI-FTC, univariate analysis identified that age ≥ 55 years (p = 0.002) and M1 (p < 0.001) were related to cause-specific survival. In 458 patients with M0 MI-FTC, male sex (p = 0.041), age ≥ 55 years (p = 0.001), and tumor size > 40 mm (p < 0.001) were related to poor disease-free survival (DFS) in univariate analysis. Multivariate analysis showed that age ≥ 55 years (p = 0.005) and tumor size > 40 mm (p = 0.005) were independent prognostic factors for DFS. The 10-year DFS rates of patients aged < 45 years, 45 years ≤ age < 55 years, and ≥ 55 years were 97.0%, 95.5%, and 86.4%, respectively.

CONCLUSIONS

The change in the recommended age for completion total thyroidectomy with RAI, from 45 to 55 years, seemed reasonable.

Distant Metastasis in Pediatric and Adolescent Differentiated Thyroid Cancer: Clinical Outcomes and Risk Factor Analyses

CONTEXT

The specific characteristics of pediatric and adolescent differentiated thyroid cancer (DTC) is the more frequent occurrence of distant metastasis (DM) compared with adult DTC.

OBJECTIVE

To investigate the clinical outcomes of DM in this population and analyze risk factors related to DM.

DESIGN, SETTING, AND PARTICIPANTS

Medical records of 171 patients with DTC < 19 years old, who underwent initial surgery between 1979 and 2014 were retrospectively reviewed.

MAIN OUTCOME MEASURE

Clinical responses to radioiodine (RAI) therapy evaluated by the American Thyroid Association (ATA) guidelines for adult DTC and Response Evaluation Criteria in Solid Tumors (RECIST) criteria. Risk factors related to distant-metastasis-free survival (DMFS).

RESULTS

DM was observed in 29 patients, and all were lung metastases. The pattern of lung metastasis was classified into 3 categories: macronodular, micronodular, and no apparent nodule (detected only by RAI scintigraphy). Patients with excellent responses according to the ATA guideline criteria or complete remission of the RECIST criteria were most frequently observed in those with no apparent nodule. Significant factors related to DMFS were sex, clinical lymph node metastasis (LNM), extrathyroidal extension, and number of LNM. Subjects were divided into 3 groups according to the number of risk factors: low risk (no risk factors); intermediate risk (1 risk factor); and high risk (≥2 risk factors). Twenty-year DMFS rates in the low-, intermediate-, and high-risk groups were 99.0%, 71.7%, and 28.6%, respectively.

CONCLUSION

To achieve the full efficacy of RAI therapy, early diagnosis of DM before apparent metastases appear is desirable. The selective approach would be preferable for pediatric and adolescent DTC.

Inflammatory biomarkers and dynamics of neutrophil-to-lymphocyte ratio in anaplastic thyroid carcinoma

PURPOSE

Studies have shown that inflammatory biomarkers, such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR), are associated with prognosis or treatment efficacy in various cancers. The present study investigated the association between the inflammatory biomarkers and dynamics of NLR, and prognosis or disease progression in anaplastic thyroid carcinoma (ATC).

METHODS

This study included 55 patients with ATC who had available complete blood count (CBC) data. Overall survival based on inflammatory biomarker value, and the dynamics of NLR among patients with ATC were investigated. Change in NLR was obtained by subtracting the baseline value from the max value obtained during follow-up period, and we subclassified 51 ATC patients who had follow-up CBC data into the increased group (change of NLR > 5.5) and non-increased group (change of NLR ≤ 5.5).

RESULTS

There were no significant differences in OS according to baseline NLR, PLR, and LMR values. Among the 51 patients with ATC who had follow-up CBC data, the median OS was 7.7 [95% confidence interval (CI): 5.2-12.1] months in the increased group (n = 27), versus 23.5 [95% CI: 13.9-not available] months in the non-increased (n = 24) group (p < 0.001).

CONCLUSIONS

The present study found no association between baseline inflammatory biomarkers and OS among patients with ATC. However, ATC patients whose NLR increased compared with individual baseline during follow-up period had worse prognosis than non-increased patients.

Clinical outcomes and risk stratification for papillary thyroid carcinoma presenting with distant metastasis before the era of tyrosine kinase inhibitors

Radioactive iodine (RAI) therapy has been the mainstay of treatment for papillary thyroid carcinoma (PTC) patients with distant metastasis (DM). Although tyrosine kinase inhibitors (TKIs) were introduced for the treatment of RAI refractory metastatic thyroid carcinoma several years ago, clinical outcomes for PTC patients with DM treated using RAI therapy remain unclear. We retrospectively examined 64 PTC patients (9 men, 55 women) with DM at diagnosis treated using RAI therapy without administration of any kind of chemotherapy or TKIs. Median age of patients was 58 years. Site of DM was the lungs (n = 59), bone (n = 3), and pleural dissemination (n = 2). No patients showed multiple-organ metastases at diagnosis. By the end of the study period, 21 patients had died of PTC. Cause-specific survival rates at 10, 15, and 20 years after initial surgery were 68.2%, 63.6% and 61.1%, respectively. Uni- and multivariate analyses identified age ≥55 years (HR 3.1, p = 0.023), site of DM other than the lungs (HR 13.4, p < 0.0001), and DM with no RAI avidity (HR 5.1, p = 0.0098) as factors independently associated with disease-related death. When analyses were restricted to patients with lung metastasis (n = 59), surgical non-curability was another independent risk factor (HR 5.2, p = 0.0047) in addition to age and RAI avidity. According to risk stratification analysis based on these risk factors, patients with site of DM other than the lungs or with lung metastasis showing ≥2 risk factors among age ≥55 years, DM with no RAI avidity, and surgical non-curability are expected to show higher mortality rates.

Urinalysis by combination of the dipstick test and urine protein-creatinine ratio (UPCR) assessment can prevent unnecessary lenvatinib interruption in patients with thyroid cancer

BACKGROUND

Proteinuria induced by lenvatinib is a class effect that occurs secondary to VEGFR suppression. Withholding of lenvatinib is required in cases with severe proteinuria. Urine protein-creatinine ratio (UPCR, g/gCre) has recently attracted attention as an alternative to 24-h urine collection for assessing proteinuria. The aim of this study was to examine the correlation between the results of proteinuria assessed by the dipstick test and UPCR, and to investigate the influence of proteinuria grading with UPCR on lenvatinib dose adjustment compared to that with only the dipstick test.

METHOD

Three hundred and ten urine samples from 63 patients with advanced thyroid cancer under treatment with lenvatinib, which were tested by both the dipstick test and UPCR were analyzed. Lenvatinib was withheld when there was evidence of CTCAE grade 3 proteinuria, and restarted when it resolved. The frequency of proteinuria, correlation between the results of the dipstick test and UPCR test, and the effect of dose withholding in cases with results of 3 + in the dipstick test were calculated.

RESULTS

Proteinuria was seen in 56 (88.9%) patients. Of the 154 dipstick 3 + samples, only 56 (36.4%) were judged as more than 3.5 g/gCre by UPCR (grade 3 proteinuria), although none of the 1 + and only 3.7% of 2 + samples were judged as grade 3 proteinuria. We were able to prevent unnecessary lenvatinib interruption due to proteinuria in 63.6% of dipstick 3 + samples by assessment of UPCR.

CONCLUSIONS

Urinalysis by combination of the dipstick test and UPCR assessment might be a better strategy for preventing unnecessary interruption of lenvatinib.

Risk Stratification of Pediatric Patients with Differentiated Thyroid Cancer: Is Total Thyroidectomy Necessary for Patients at Any Risk?

Background: In the recent American Thyroid Association (ATA) guidelines for adult differentiated thyroid carcinoma (DTC) patients, risk stratification is clearly defined and lobectomy is acceptable for low-risk DTC. However, risk stratification for children with DTC in the ATA pediatric guidelines is rather unclear, and total thyroidectomy is recommended for all patients with any risk. The aim of this study was to attempt risk stratification based on our experience and to consider the appropriate extent of thyroidectomy, especially for low-risk DTC in the pediatric population. Patients and Methods: The subjects were 153 patients with DTC ≤18 years old, including 58 patients ≤15 years old and 136 female patients, who underwent initial curative surgery in our hospital between 1979 and 2014. Underlying pathology was papillary thyroid carcinoma in 130 patients and follicular thyroid carcinoma in 23. Risk factors related to disease-free survival (DFS) were analyzed and risk stratification was performed. Results: No patient died of the disease and 34 patients (22.2%) developed recurrences. At initial surgery, 30 patients (19.6%) had lymph node metastases diagnosed before initial surgery (cN1) and 9 (5.9%) had gross extrathyroidal extension (ETE). Significant factors related to DFS on multivariate analysis were cN1, ETE, and number of metastatic lymph nodes (NMLNs) ≥10, including microscopic MLNs. According to these factors, subjects were divided into three categories: low risk (no risk factors, n = 89); intermediate risk (1 risk factor, n = 37); and high risk (≥2 risk factors, n = 27). Ten-year DFS rates in the low-, intermediate-, and high-risk groups were 96%, 83%, and 48%, respectively. Only 12% of low-risk patients underwent total thyroidectomy. Because NMLNs become obvious only after surgery, another analysis after excluding "NMLNs" as a factor showed that cN and ETE were significant factors related to poor DFS. According to these two factors, risk stratification was attempted in the same manner. Ten-year DFS rates in the low- (no risk factor, n = 117), intermediate- (one risk factor, n = 29), and high-risk (two risk factors, n = 7) groups were 92%, 59%, and 43%, respectively. Only 12% of low-risk patients underwent total thyroidectomy. Conclusions: For low-risk pediatric patients, lobectomy may be sufficient as the initial surgical procedure.

Sarcopenia is a prognostic factor for TKIs in metastatic thyroid carcinomas

PURPOSE

Among patients with various cancers receiving anticancer drugs, sarcopenia is associated with poor survival and treatment outcomes. We conducted an observational study using skeletal muscle index (SMI) evaluation to investigate the association between sarcopenia and treatment outcomes of tyrosine kinase inhibitors (TKIs) in metastatic thyroid cancer patients.

METHODS

We included 54 patients (19 men, 35 women; age, 66.5 ± 10.9 years) with differentiated thyroid carcinoma (DTC) or medullary thyroid carcinoma (MTC). The records of patients with metastatic DTC and MTC treated with TKIs were retrospectively reviewed. Patients were divided into sarcopenia and non-sarcopenia groups based on SMI. The SMI cutoff values for sarcopenia were 42 and 38 (cm²/m²) for males and females, respectively. Thirty-three patients had sarcopenia before TKI treatment.

RESULTS

The sarcopenia group had more females and a lower body mass index. The median progression-free survival (PFS) durations were 13.6 (95% confidence interval (CI): 6.1-29.9) and 41.9 (95% CI: 25.2-not estimable) months in the sarcopenia and non-sarcopenia groups (p= 0.017), respectively. Univariate analysis showed that sarcopenia was significantly associated with PFS (p= 0.037). Sex, age, and performance status did not affect PFS. Multivariate analysis showed that sarcopenia was the only independent prognostic factor for PFS (hazard ratio: 2.488, 95% CI: 1.058-5.846, p= 0.037).

CONCLUSIONS

Sarcopenia could be a predictive factor of TKI treatment outcomes in patients with metastatic thyroid cancer as well as intervention target to improve prognosis. Further prospective investigations are needed to confirm these preliminary data.

Rapid disease progression after discontinuation of lenvatinib in thyroid cancer

Some thyroid cancer patients experience a rapid disease progression after the discontinuation of tyrosine kinase inhibitors (TKIs), which is called flare phenomenon. The incidence of the flare phenomenon of epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) ranged from 4% to 11.1% and the median time to occurrence of the flare phenomenon ranged from 7 to 12 days in previous reports. In this study, we investigate the timing and incidence of the flare phenomenon in thyroid cancer patients treated with lenvatinib.The records of patients treated with lenvatinib were retrospectively reviewed. The primary outcomes were the incidence rate and timing of the flare phenomenon after the discontinuation of lenvatinib. The flare phenomenon was defined as death, hospitalization attributable to tumor progression, or unexpected event (e.g., pleural drainage) within 1 month of lenvatinib cessation. We excluded patients with progression of underlying diseases other than thyroid cancer or infection, those in whom the disease progressed, or those who died without achieving a clinical response (stable disease, partial response, or complete response).In total, 8 (14.3%) of the 56 patients experienced the flare phenomenon. The median time from lenvatinib cessation to the flare phenomenon was 9 (range, 4-30) days. Three patients in the flare group died within 1 month of lenvatinib cessation without an imaging evaluation. The remaining 5 patients had dyspnea and pleural effusion, and pleural drainage was performed in 3 of the 5 patients. Lenvatinib was resumed in 4 of the 8 patients in the flare group. Median overall survival (OS) was 15.1 months in the flare group and 41.9 months in the non-flare group. The OS tended to be poor in the flare group than in the non-flare group; however, this difference was not statistically significant (P = .051).In lenvatinib treatment for thyroid cancer, the incidence and timing of the flare phenomenon were similar to those observed with other TKIs. OS tended to be poor in the flare group than in the non-flare group. Further studies are needed to determine the mechanism of the flare phenomenon and establish measures and treatment policies.

Efficacy and Limitations of Lenvatinib Therapy for Radioiodine-Refractory Differentiated Thyroid Cancer: Real-World Experiences

Background: The ultimate clinical goal of advanced cancer treatment is improvement of survival. Tyrosine kinase inhibitors (TKIs) were recently approved for radioiodine-refractory differentiated thyroid carcinoma (RR-DTC) that is resistant to conventional therapies since they have significant potential to improve survival in patients who previously had no more treatment strategies available. However, eligible patients are limited in clinical practice, making it difficult to accurately determine the efficacy of TKIs. Patients and Methods: We retrospectively analyzed the efficacy of lenvatinib at a single institution, enrolling 42 RR-DTC patients. Results: The best overall response was partial remission in 26 (62%) patients, stable disease in 10 (24%) patients, and progressive disease (PD) in 6 (14%) patients. The results indicated three-year overall survival (OS) and progression-free survival rates of 51.0% and 32.4%, respectively. Twenty-three (55%) patients had backgrounds that did not match the inclusion criteria of the Study of (E7080) Lenvatinib in Differentiated Cancer of the Thyroid (SELECT) trial. Furthermore, PD-experienced patients individually decided whether to continue lenvatinib, and 17 (41%) made the decision themselves; these patients had a three-year OS of 43.0% and postprogression survival (PPS) of 13.3 [95% confidence interval 6.1-not reached] months. Conclusions: Our real-world investigation revealed that patients have wide-ranging background characteristics, and the decision regarding continuation of therapy after PD is based on the patient's general condition. Our management protocol resulted in good PPS. Furthermore, our results indicated equivalent efficacy of lenvatinib as in the SELECT trial. In conclusion, lenvatinib proved effective for RR-DTC patients in a real-world setting.

Stereotactic radiotherapy using the CyberKnife is effective for local control of bone metastases from differentiated thyroid cancer

Differentiated thyroid cancer (DTC) is associated with a good long-term prognosis, but bone metastases can adversely affect patients' quality of life and survival. Stereotactic radiotherapy (SRT) can deliver high-dose irradiation to target lesions and it has been reported to be useful for various cancers. However, few studies have examined the efficacy of SRT for thyroid cancer. In the present study, the aim was to investigate the efficacy of SRT using the CyberKnife for bone metastases from DTC. From September 2013 to April 2018, SRT with the CyberKnife system was used to treat 60 bone metastases from DTC in 13 patients. The patients' medical records were retrospectively reviewed to obtain information about the adverse events associated with SRT. Of the 60 lesions, 40 could be evaluated by follow-up CT for therapeutic effectiveness, and the RECIST criteria were used to assess the response. The cancers were papillary cancer in 3 patients, follicular cancer in 9 and poorly differentiated cancer in 1. SRT was delivered in 1-10 fractions, with a median dose of 27 Gy (range, 8-48 Gy). Adverse events were infrequent and mild. The median follow-up of the 40 lesions was 11 (range, 2-56) months. The responses were partial response in 2 lesions, stable disease in 37 lesions and progressive disease in 1 lesion, with a 1-year local control rate of 97.1%. The present study showed that SRT using the CyberKnife system was a feasible and effective treatment for bone metastases of DTC.

Usefulness of Stereotactic Radiotherapy Using the CyberKnife for Patients with Inoperable Locoregional Recurrences of Differentiated Thyroid Cancer

BACKGROUND

Surgical resection is the preferred treatment for locoregional recurrence of differentiated thyroid cancer (DTC). However, some recurrences are unresectable because of their aggressive invasion or severe adhesions. On the other hand, stereotactic radiotherapy (SRT) enables high-dose irradiation to target lesions, and its usefulness for various cancers has been reported. The objective of the present study was to investigate the feasibility and efficacy of SRT as salvage treatment for locoregional recurrence of DTC.

METHODS

Between August 2011 and December 2017, 52 locoregional recurrent lesions in 31 patients with recurrent DTC were treated by SRT using the CyberKnife system. Information on the adverse events associated with SRT was retrospectively collected from the patients' medical records. Of the 52 lesions, 33 could be evaluated for therapeutic effectiveness by follow-up CT, and response was assessed using the RECIST criteria.

RESULTS

Twenty-five patients had papillary carcinoma, 5 had follicular carcinoma, and 1 had poorly differentiated cancer. SRT was delivered in one to 20 fractions, and the median dose was 30 Gy (range 15-60 Gy). Adverse events were not frequent, but 1 patient developed bilateral vocal cord palsy that required emergent tracheostomy. The median follow-up period of 33 lesions was 14 months (range 1-54 months). Complete response, partial response, stable disease, and progressive disease were seen in 10, 11, 9, and 3 patients, respectively. The 3-year local control rate was 84.6%.

CONCLUSION

SRT using the CyberKnife system was found to be a feasible and effective treatment to suppress the growth of locoregional recurrence of DTC.

MON-552 Prognostic Impact of the Turin Criteria in Poorly Differentiated Thyroid Carcinoma

Background Poorly differentiated thyroid carcinoma (PDTC) is morphologically and behaviorally intermediate between differentiated carcinoma and anaplastic carcinoma. The Turin criteria including solid, trabecular, and/or insular architecture, lack of typical nuclear features of papillary carcinoma, and mitoses, necrosis, or convoluted nuclei were adopted in the recent 4^th edition of the World Health Organization (WHO) classification published in 2017. Materials and Methods Between 2006 and 2017, 11,001 cases underwent initial surgery for primary malignant thyroid tumor derived from follicular cells. A total of 75 (0.7%) cases were diagnosed with PDTC according to the 3^rd WHO classification. Based on the Turin criteria (4^th WHO classification), 30 (40%) cases were re-classified as PDTC-Turin (+), and 45 (60%) cases were PDTC-Turin (-). Clinicopathological features and prognosis were compared between PDTC-Turin (+) and PDTC-Turin (-). Result The 75 patients (48 females, 27 males) had a median age at the time of surgery of 57 years. The 5-year cause-specific survival (CSS) and disease-free survival (DFS) rates were 96.4% and 38.6% for PDTC-Turin (+), and 100% and 88.4% for PDTC-Turin (-), respectively. On univariate analysis, CSS and DFS rates were significantly worse in the PDTC-Turin (+) cases than in the PDTC-Turin (-) cases (log-rank test, p=0.005, and p=0.0004). Multivariate analysis showed that Turin criteria status was an independent prognostic factor for recurrence. Conclusion The prevalence of PDTC diagnosed with the Turin criteria was low, but it showed more aggressive behavior. The 4^th WHO classification reflects the prognosis more accurately than the 3^rd WHO classification.

Change of surgical strategy for Graves' disease from subtotal thyroidectomy to total thyroidectomy: a single institutional experience

The extent of thyroidectomy in Graves' disease remains controversial. In our institution, long-term euthyroidism without thyroxin replacement therapy has been the aim, and it has long been the standard surgical procedure used to treat Graves' disease in many institutions, including our hospital. Based our several clinical studies, it was concluded that subtotal thyroidectomy is not suitable as a standard surgical procedure for the treatment of Graves' disease. In 2009, the surgical strategy for Graves' disease was changed from subtotal thyroidectomy to total thyroidectomy in our hospital. In this study, how surgical complications have changed after this modification was examined. The subjects were 1,476 patients with Graves' disease treated by thyroidectomy between 2006 and 2014. There were 1,119 females and 357 males with a median age of 39 years. A total of 660 patients underwent bilateral subtotal thyroidectomy (ST group), and 816 patients underwent total thyroidectomy (TT group). Both transient hypocalcemia and prolonged hypocalcemia were observed significantly more frequently in the TT group than in the ST group (p < 0.001). Total thyroidectomy was identified as risk factors for prolonged hypocalcemia on multivariate analysis. In conclusion, total thyroidectomy is a reliable and effective therapy for controlling hyperthyroidism in terms of controlling of hyperthyroidism. However, it should be noted that total thyroidectomy resulted in increased rate of prolonged hypocalcemia. Surgeons should try to reduce the surgical complication rate as much as possible.

Cribriform-Morular Variant of Papillary Thyroid Carcinoma: Clinical and Pathological Features of 30 Cases

BACKGROUND

Cribriform-morular variant of papillary thyroid carcinoma (CMV-PTC) is rare; it may occur in cases of familial adenomatous polyposis (FAP) or be sporadic. To clarify the clinicopathological features of CMV-PTC, the medical records of these patients were investigated retrospectively.

MATERIALS AND METHODS

Between 1979 and 2016, a total of 17,062 cases with PTC underwent initial surgery at Ito Hospital. Of these, 30 (0.2%) cases histologically diagnosed with CMV-PTC were reviewed.

RESULT

The patients were all women, with a mean age at the time of surgery of 24 years. Seven (23%) cases were thought to have FAP because they had colonic polyposis or a family history of FAP or APC gene mutation. The remaining 23 (77%) were thought to be sporadic. Multiple tumors were detected in 6 cases, with a solitary tumor in 24. One patient had lung metastasis at diagnosis. Eleven patients underwent total thyroidectomy or subtotal thyroidectomy, and 19 underwent lobectomy. Twenty-six (87%) patients underwent neck lymph node dissection. Three patients had tumor metastasis in central lymph nodes, but these were incidentally detected metastatic classical PTC (cPTC) based on histological examination. In this series, there were no cases of LN metastases of CMV-PTC. During a mean follow-up of 15 years, one patient had new cPTC in the remnant thyroid after initial surgery, and the other patients showed no signs of recurrence.

CONCLUSION

CMV-PTC occurred in young women, their long-term prognosis was excellent. Total thyroidectomy is recommended for FAP-associated CMV-PTC, but modified neck lymph node dissection is not necessary.

Clinical factors related to the efficacy of tyrosine kinase inhibitor therapy in radioactive iodine refractory recurrent differentiated thyroid cancer patients

New insights in thyroid cancer biology propelled the development of targeted therapies as salvage treatment for radioiodine-refractory differentiated thyroid cancer (RR-DTC), and the tyrosine kinase inhibitor (TKI) lenvatinib has recently become available as a new line of therapy for RR-DTC. The aim of this study is to investigate clinical factors related to the efficacy of TKI therapy in recurrent RR-DTC patients and identify the optimal timing for the start of TKI therapy. The subjects consisted of 29 patients with progressive RR-DTC, 9 males and 20 females, median age 66 years. A univariate analysis was conducted in relation to progression free survival (PFS) and overall survival (OS) by the Kaplan-Meier method for the following variables: age, sex, histology of the primary tumor, thyroglobulin doubling time before the start of lenvatinib therapy, site of the target lesions, presence of a tumor-mediated symptom at the start of lenvatinib therapy, and baseline tumor size of the target lesions. Median duration of lenvatinib therapy was 14.7 months and median drug intensity was 9.5 mg. At the time of the data cut-off for the analysis, 9 patients (31.0%) have died of their disease (DOD), and a PR (partial response), SD (stable disease), and PD (progressive disease) were observed in 20 patients (69%), 6 patients (20.7%), 3 patients (10.3%), respectively. Univariate analyses showed that the presence of a symptom was the only factor significantly related to poorer PFS and OS. Clinical benefit of TKI therapy will be possibly limited when the therapy starts after tumor-mediated symptoms appear.

Globus Symptoms in Patients Undergoing Thyroidectomy: Relationships with Psychogenic Factors, Thyroid Disease, and Surgical Procedure

BACKGROUND

The number of patients who need thyroid surgery has increased worldwide in recent decades. Patients with thyroid disease experience globus pharyngeus as a result of direct compression and edema of the surrounding organs. Thyroid surgery is needed to improve these symptoms or as treatment for thyroid cancer. After thyroid surgery, globus symptoms may become worse and may affect the daily life of the patient for a long time. Psychogenic problems have also been thought to cause the globus sensation. A prospective analysis of globus symptoms and psychogenic factors following thyroidectomy was performed.

MATERIAL AND METHODS

Patients scheduled to undergo thyroid surgery between February and September 2016 completed the foreign-body sensation in the throat score (FBST; range 0-8.2) and the self-rating depression scale (SDS; range 0-100) preoperatively and three days, one month, three months, six months, and 12 months postoperatively.

RESULTS

Long-term follow-up was completed in 616 patients (491 females). A total of 365 patients had thyroid cancer, 169 had benign tumors, and 82 had diffuse goiters with Graves' disease. The percentage of patients who complained about neck discomfort (FBST >2) was 29.4% before surgery. A preoperative high FBST showed a significant direct correlation with a high SDS, but thyroid volume did not. A postoperative high FBST was seen in 75.3% of patients at two days and 78.9% at one month after surgery, and it then gradually decreased to 49.3% at 12 months after surgery. At three days after the operation, the median FBST was significantly higher in patients who had total thyroidectomy with lateral neck dissection or total thyroidectomy only compared to those who had lobectomy only (p < 0.05). These differences were still present 12 months after surgery. A higher preoperative SDS score was also identified as an independent predictor for a high FBST at 12 months after surgery, but not at one or three months postoperatively, on multivariate analyses.

CONCLUSION

Preoperative globus symptoms appear directly related to psychological factors. The area of the surgical procedure and preoperative psychological factors were related to persistent neck discomfort.

Lenvatinib induces early tumor shrinkage in patients with advanced thyroid carcinoma

Although advanced thyroid carcinoma patients who cannot be cured by conventional therapy have lacked effective treatment, multitargeted tyrosine kinase inhibitors have recently become available. Phase 3 trials of lenvatinib showed a median time to objective response of 2 (95 % confidence interval (CI) 1.9-3.5) months, demonstrating that shrinks tumors rapidly. The phenomenon of immediate tumor shrink is known as early tumor shrinkage (ETS) which is related to clinical outcome in other malignancies. However, precisely when within 8 weeks lenvatinib starts to affect tumors remains unclear. In tumors near the carotid arteries, trachea, or esophagus, a rapid therapeutic effect can induce fistula formation or arterial bleeding. To prevent such treatment-emergent serious adverse events (SAE), early imaging evaluation seems to be very important. In this study, the point in time when lenvatinib started to shrink tumors was retrospectively investigated. The subjects were 16 patients who started lenvatinib administration between May and August 2015. Tumor size was evaluated by computed tomography (CT) scans frequently within the first 8 weeks according to the Response Evaluation Criteria In Solid Tumors (RECIST) guideline. Initial tumor response was defined as ≥ 10% tumor reduction. Serum thyroglobulin (Tg) level was monitored in 8 differentiated thyroid carcinoma (DTC) without TgAb patients. At the first evaluation, 13 patients (83.3 %) showed tumor reduction and that decreased with time. Thirteen patients (83.3 %) showed >10 % tumor reduction within 8 weeks. In all DTC patients, serum Tg level was markedly decreased. In conclusion, lenvatinib immediately shrinks tumors, the so-called ETS phenomenon. Therefore, careful attention should be paid to fistula formation from the early phase.

Cervical Lymph Node Metastases After Thyroidectomy for Papillary Thyroid Carcinoma Usually Remain Stable for Years

BACKGROUND

Lymph node (LN) recurrence detected by ultrasound (US) is a very common problem after initial treatment for papillary thyroid carcinoma (PTC). Most patients with PTC have an excellent disease-specific survival even with LN recurrence. Recently, watchful waiting with serial cervical US evaluations would be considered a reasonable approach to management of LN recurrence in selected patients. On the other hand, some patients with LN recurrence have demonstrated clinically significant disease progression during follow-up. The objective of the present study was to document the changes of cervical LN metastases after initial treatment and identify useful information for deciding how best to manage individual patients with LN recurrence.

METHODS

This retrospective review identified 83 consecutive PTC patients with at least one LN on the postoperative US diagnosed with fine needle aspiration biopsy or the thyroglobulin titer in the wash-out of the needle. The change in LN size was determined using serial US studies over time.

RESULTS

The subjects were 15 men and 68 women, with a median age at initial surgery of 50.6 years (range, 18-80 years). The median LN size at the start of the observation period was 1.3 cm (range, 0.5-2.4 cm) in the largest diameter. After a median follow-up of 7.2 years, the median growth rate of the nodes showing structural progression was 1.4 mm per year (range, 0-12.0 mm/year). Seventeen of 83 patients (20.5%) demonstrated an increase in LN size of at least 3 mm, only 8.4% (7 of 83) had an increase of at least 5 mm, and 39.7% (33 of 83) resolved. Distant metastases were present in 11 of 83 patients. Ten-year and fifteen-year disease-specific survival rates after diagnosis of LN recurrence were 84.7% and 72.6%, respectively. Older age and recurrent LN growth of more than 3 mm/year were recognized as independent predictors for short survival on both univariate and multivariate analyses (p < 0.05).

CONCLUSIONS

Most lymph node recurrences may remain stable for a long time and not be immediately life-threatening. However, recurrent LN growth of more than 3 mm per year could be related to mortality.

Outcome and characteristics of patients with malignant pleural effusion from differentiated thyroid carcinoma

Metastatic differentiated thyroid carcinoma (DTC) is an uncommon cause of malignant pleural effusion (MPE) and the characteristics and clinical course have been rarely described. Herein, we report a retrospective review of the clinical course of 18 patients (15 women and 3 men) with MPE from DTC who underwent treatment at our institution between January 2005 and December 2014. MPE from DTC was diagnosed based on cytology and/or level of thyroglobulin in the pleural fluid. Pathologically, papillary carcinoma was found in 16 patients and follicular carcinoma in 2 patients. Median ages at initial diagnosis of DTC and MPE were 64 years (range, 22-79) and 74 years (range, 39-86), respectively. All patients showed radiologically apparent lung metastases, with MPE developing after 0-212 months (median, 25). In 16 patients (88.9%), other coexistent distant metastases at the time of MPE diagnosis were found in the bone (n = 10), brain (n = 5), and skin (n = 2). All patients were treated conservatively with palliative thoracentesis or chest tube drainage with or without pleurodesis. Recurrent MPE after treatment was seen in 9 patients; discharge to home health care after treatment for MPE was possible for 14 patients. The overall survival after initial diagnosis varied considerably from 14 months to 37 years, but the median survival after appearance of MPE was 10 months (range, 1-28). Systemic therapy for iodine-resistant recurrent thyroid disease may need to be considered as a treatment option for patients with MPE.

Prognostic significance of patient age in minimally and widely invasive follicular thyroid carcinoma: investigation of three age groups

Follicular thyroid carcinoma (FTC) is the second most common malignancy arising from follicular cells. It is classified into two categories based on the degree of invasion: widely and minimally invasive FTC. Here we focused on the prognostic value of patient age in FTC. We enrolled 292 minimally invasive and 79 widely invasive FTC patients who underwent initial surgery between 1983 and 2007. We classified these patients into three groups based on patient age: < 20 years (children and adolescents), 20-44 years (young adults) and ≥ 45 years (middle-aged or older), and compared their prognoses disease-free survival (DFS) and cause-specific survival (CSS). Among the minimally invasive FTC patients, those aged ≥ 45 years showed a poorer DFS and CSS than those < 45 years. In the subset of patients < 45 years, the DFS of patients < 20 years tended to be poorer than those aged 20-44 years, but none of the patients < 20 years died of FTC. Among the patients with widely invasive FTC, only three were younger than 20 years old. Two patients showed carcinoma recurrence, but neither died of FTC. In minimally invasive FTC, the DFS showed a biphasic pattern, but the CSS became poorer with increasing age. In widely invasive FTC, similar to minimally invasive FTC, patients < 20 years might be likely to show recurrence but are unlikely to die of FTC, although studies using larger number of patients are necessary before drawing any conclusions.

Voice quality after surgical treatment for thyroid cancer

BACKGROUND

Thyroidectomy is a standard treatment for thyroid cancers. Hoarseness due to the paralysis of the recurrent laryngeal nerve is one of the most common postoperative complications, and has been studied by many investigators. However, voice quality after thyroidectomy in patients in whom recurrent laryngeal nerves were preserved and vocal cord morbidity was endoscopically normal has not been well studied. To understand voice quality after thyroidectomy further, we conducted a time-course analysis of voice quality in patients who had thyroidectomy with normal cord morbidity by various measures.

METHODS

We evaluated voice parameters including the Voice Handicap Index-10 (VHI-10), the vocal efficacy index, the fundamental frequency (F0), the maximum phonation time (MPT), the mean air flow rate (MFR), jitter, shimmer, and the noise-to-harmonics ratio (NHR) before and after total thyroidectomy (TT) or lobectomy (LO) for thyroid cancers in 110 patients in whom the recurrent laryngeal nerves were preserved without apparent injury and normal vocal cord mobility was confirmed by endoscopic examination. Thirteen patients who underwent parotidectomy were enrolled as controls.

RESULTS

Immediately after surgery, significant decreases in MPT (p=0.003) and significant increases in jitters, shimmers, and NHR (p=0.0002, 0.02, and 0.03, respectively) were observed in the patients who underwent TT. In comparison with the controls, jitters and NHR were significantly higher in the patients who had a TT (p=0.03, 0.04). MFR was significantly higher in the patients who had an LO than in the controls (p=0.02). As compared with the patients who had an LO, MPT was significantly shorter (p=0.0004) and MFR and NHR were significantly higher (p=0.004, 0.03) in the patients with a TT. In the patients who had a TT, the MPT immediately after the surgery was significantly longer in the patients who had simultaneously neck dissection (ND) in comparison with the patients who did not have ND. However, all these differences gradually decreased and were not significant at one month after surgery.

CONCLUSIONS

Our results suggest that TT and ND have a distinct impact on voice quality after surgical treatment for thyroid cancer, probably due to slight and transient nerve conduction disorders induced by the manipulation around recurrent laryngeal nerves and/or laryngeal edema induced by the disturbance of venous and lymphatic drainages. However, these changes appear to be temporary, lasting only a few weeks.

Undetectable serum thyroglobulin levels in patients with medullary thyroid carcinoma after total thyroidectomy without radioiodine ablation

BACKGROUND

Recently, we reported that the thyroglobulin (Tg) doubling time (DT) was the most potent prognostic factor in patients with papillary thyroid carcinoma (PTC) who underwent total thyroidectomy. Interestingly 16.2% of the study patients had a decrease in Tg levels over time, giving negative values in Tg-DT. These patients had an excellent outcome. However, most of the patients did not receive ablation with radioactive iodine. Therefore, whether the Tg in these patients was derived from persistent disease or residual thyroid tissue could not be concluded. To resolve this question, we measured serum Tg levels in patients with medullary thyroid carcinoma (MTC) who underwent total thyroidectomy using similar surgical techniques for the treatment of PTC.

METHODS

Twenty-seven consecutive patients with MTC who underwent total thyroidectomy were selected. Of them, five patients with antibodies to Tg were excluded from the study. In the remaining 22 patients, serum Tg levels were measured before and after surgery. None of the patients received radioactive iodine ablation. They were prescribed levothyroxine as a replacement for the lost thyroid function.

RESULTS

Serum Tg levels were detectable preoperatively, while postoperative serum Tg levels were lower than the detectable level, 0.5 ng/mL, in all 22 patients.

CONCLUSIONS

The results indicate that most of the patients with detectable Tg levels and negative Tg-DT values after total thyroidectomy for PTC in our previous study had persistent disease, and that their serum Tg was not from residual thyroid tissue, suggesting that up to 50% of patients with persistent PTC have a decrease in serum Tg levels in response to thyroid-stimulating hormone-suppressive therapy.

Imaging studies in sixty patients with acute suppurative thyroiditis

BACKGROUND

Pyriform sinus fistulae are the major routes of infection in acute suppurative thyroiditis (AST). There have been only a few reports describing imaging studies in AST. We reviewed our imaging studies in patients with AST to elucidate its features so as to facilitate its diagnosis and treatment.

METHODS

We reviewed ultrasonography (US) examinations, computed tomography (CT) scans, and barium swallow studies performed on 60 patients with the AST who were seen for medical care between 1998 and 2008 and were retrospectively reviewed. All of these patients had pyriform sinus fistulae.

RESULTS

In the acute inflammatory stage, US showed a hypoechoic lesion spreading in and around the affected thyroid lobe, destruction of the lobe, and abscess formation in the neck. CT scans demonstrated similar features with clearer anatomical involvement and edema in the ipsilateral hypopharynx. These findings allowed easy diagnosis of AST. However, in the early inflammatory stage US showed an unclear hypoechoic area in the affected lobe and CT scans showed a nonspecific low-density area. These findings often led to erroneous diagnoses of subacute thyroiditis. A careful review of the US studies demonstrated that the following findings are characteristic of acute suppurative thyroidits: a perithyroidal hypoechoic space, effacement of the plane between the thyroid and perithyroid tissues, and the hypoechoic lesions being unifocal. The former two are not seen in subacute thyroiditis, and hypoechoic lesions in subacute thyroiditis are usually multiple and often bilateral. In the late inflammatory stage, US and CT scans often showed atrophy and an unclear hypoechoic or low-density area in and around the affected lobe. To detect pyriform sinus fistulae, barium swallow studies are more sensitive than US or CT scans.

CONCLUSION

During the acute inflammatory stage of AST, both US and CT scans showed inflammatory processes in and around the affected thyroid lobe, although the CT scans more clearly demonstrate the anatomical locations involved. In the early inflammatory stage, these features may lead to an erroneous diagnosis of subacute thyroiditis. Careful US studies should indicate the correct diagnosis, which can then be proven by a barium swallow study or fine-needle aspiration followed by cytological examination and bacterial culturing.

Prognostic impact of serum thyroglobulin doubling-time under thyrotropin suppression in patients with papillary thyroid carcinoma who underwent total thyroidectomy

BACKGROUND

Detectable serum thyroglobulin (Tg) in patients with papillary thyroid carcinoma (PTC) after total thyroidectomy implies unsuccessful surgery, indicating a high risk of recurrence. Serum Tg kinetics in such patients have not been extensively studied. We studied serum Tg kinetics in patients with suppressed serum thyrotropin levels and undetectable anti-Tg antibody to minimize the effects of these factors on Tg values, and evaluated the relationship of prognosis to the serum Tg doubling-time.

METHODS

Between January 1998 and December 2004, 1515 patients with PTC underwent total thyroidectomy in Kuma Hospital. After excluding patients with other thyroid cancers and those positive tests for anti-Tg antibody, there were 426 patients with 4 or more serum Tg measurements at a time that serum thyrotropin concentrations were <0.1 mIU/L. These patients were selected for the present retrospective study. Tg doubling-time was computed using Tg values measured during routine follow-up. Patients were followed for a mean of 88.1 months and a median of 86.7 months.

RESULTS

Of the 426 patients, 137 patients had 4 or more measurements that revealed detectable Tg in serum Tg. The Tg doubling-time (DT), calculated using all available data, varied widely, and were grouped into those that were <1 year (17 patients), those that were 1-3 years (21 patients), and those that were ≥ 3 years (30 patients), as well as those with a negative value due to decrease in serum Tg (69 patients). There were also 88 patients who had three or fewer serum Tg measurements that showed detectable Tg levels, as well as 201 patients in whom serum Tg measurements were below the lower limit of detection. In the group of patients with a Tg-DT of <1 year the cause specific survival at 10 years was 50%, and in the group with a Tg-DT of 1-3 years it was 95%. In all other groups it was 100%. Many classical prognostic factors (TNM stage, age, and gender) as well as the Tg-DT were significant indicators of survival by univariate analysis, but Tg-DT remained the only independent predictor by multivariate analysis. Tg-DT was also the only independent predictor of distant metastases and loco-regional recurrence on multivariate analysis. Tg-DT calculated using only the first four data [Tg-DT (first four data)] was also the only independent predictor of survival, distant metastases, and loco-regional recurrence on multivariate analysis.

CONCLUSIONS

Tg-DT (all data or first four data) is a very strong prognostic predictor superior to the classical prognostic factors in patients with PTC.

Tumor thrombus of thyroid malignancies in veins: importance of detection by ultrasonography

BACKGROUND

Tumor thrombus in the thyroid vein or the internal jugular vein may be caused by thyroid malignancies. Therefore, a tumor thrombus is very suspicious for malignancy. Total thyroidectomy should be performed in such patients if there is a primary thyroid tumor, and a high probability of pulmonary metastasis seems likely as there is direct exposure of malignant cells to the circulation. Our study was performed to determine whether ultrasonography is an effective preoperative modality to detect tumor thrombi of thyroid malignancies and whether tumor thrombi are associated with pulmonary metastases.

METHODS

Between 2004 and 2009, all thyroid surgery patients at Kuma Hospital had preoperative neck ultrasonography to look for tumor thrombi in the thyroid veins and the internal jugular veins as well as thyroid masses and abnormal lymph nodes. We looked for solid masses with an echogenic "tongue" in the internal jugular vein and masses with a projection from thyroid tumor to the thyroid vein on grayscale ultrasonography. We also used Doppler ultrasonography to look for the absence of blood flow.

RESULTS

Among 7754 patients who had thyroid surgery, there were 9 patients with tumor thrombi. In seven of the patients, tumor thrombi were detected by preoperative ultrasound, and in the remaining two patients, tumor thrombi were detected during surgery. Tumor thrombi were identified in the internal jugular vein in six patients and in the thyroid vein in three patients. Pulmonary metastases were present in three patients (50% of the patients with thyroid carcinoma). The patients with tumor thrombi were more likely (33.3%) to have pulmonary metastasis than those without (0.9%) tumor thrombi (p < 0.0001). In four patients with papillary carcinoma, projection-like lesions of irregularly shaped tumors were misdiagnosed to be tumor thrombi in the thyroid veins on preoperative ultrasound. These four patients did not have pulmonary metastases.

CONCLUSIONS

The preoperative detection of a tumor thrombus on ultrasonography has important clinical significance. Therefore, preoperative neck ultrasound in patients with thyroid masses should attempt to determine whether there are signs of tumor thrombi as well as to characterize the nature and location of abnormal thyroid and extrathyroid masses.

Role of ultrasonography in patients with cytologically follicular thyroid tumor

OBJECTIVE

The purpose of this study is to evaluate the role of ultrasonography (US) in the management of thyroid nodules when the cytology is indeterminate as follicular tumor on fine needle aspiration biopsy (FNAB).

METHODS

In 2006, 6586 patients with thyroid nodules, which were detected on US underwent FNAB in our department. Of these patients, we extracted 438 patients (6.7%) whose nodules were cytologically diagnosed as indeterminate. Of them, 227 patients were diagnosed as follicular tumor were enrolled in this study. Surgery was performed according to our criteria for surgical indication. We compared the results of clinical findings including US classification and final histopathological diagnosis.

RESULTS

One hundred thirty-seven of 227 underwent surgical treatment. Thirty-three (24%) were diagnosed as malignancy pathologically. Large nodule or high serum thyroglobulin level were not associated with an increased risk of malignancy. Ultrasonographic evaluation as malignancy was directly linked to pathological diagnosis as thyroid carcinoma (p<0.0001).

CONCLUSION

US plays a crucial role in deciding whether surgical treatment is necessary for cytologically indeterminate thyroid nodules as follicular tumor.

A novel role for Niemann-Pick disease type 2C protein in papillae formation

Background

Despite the presence of papillary structures and papillary tumors in humans, the mechanism of papillae formation is unknown. We describe herein a novel role for Niemann-Pick disease type 2C (NPC2) protein, a cholesterol binding protein in the lysosome, in papillae formation.

Methodology/Principal Finding

We examined NPC2 protein expression in surgical samples of papillary tissues by immunohistochemical stain, and all papillary tissues expressed NPC2 protein in the epithelium. To examine our hypothesis of NPC2 protein-mediated papillae formation, we carried out xenograft experiments using wild H460 cells (large cell lung carcinoma cell line) that constitutively expressed abundant NPC2 protein and NPC2 protein-depleted H460 cells by NPC2 shRNA. The xenografts of wild H460 cells and empty shRNA vector cells showed distinct papillae formation, whereas NPC2 protein-depleted H460 cells displayed markedly reduced or no papillae. Since all papillary tissues have open spaces we examined whether NPC2 protein might also contribute to the creation of open spaces. The TUNEL assay in the xenografts of wild and empty shRNA vector H460 cells showed massive cell death, and NPC2 protein-depleted cells displayed minimal cell death. Measurement of caspase 3/7 activities in cultured H460 cells supported NPC2 protein-mediated apoptotic cell death. The presence of excess NPC2 protein, however, did not always produce papillae as seen in the xenografts of CHO cells that were stably transfected with NPC2.

Conclusions/Significance

The NPC2 protein of certain cells forms papillae coupled with apoptosis that creates open space. This protein may have future applications to modulate papillae formation and papillary growth in tumor tissues.

Subclinical hypothyroidism following hemithyroidectomy: a simple risk-scoring system using age and preoperative thyrotropin level

Hypothyroidism can be a complication after a hemithyroidectomy. The aim of this study was to determine the incidence and risk factors of hypothyroidism after a hemithyroidectomy. We also recommend a risk-scoring system that can predict post-hemithyroidectomy hypothyroidism before surgery. Among 260 patients who underwent hemithyroidectomy from January to June 2005, a total of 233 were euthryoid preoperatively and were followed for more than 3 years. Biochemical subclinical hypothyroidism developed in 57 patients (24.4%). Patients who developed postoperative hypothyroidism showed higher preoperative thyroid stimulation hormone (TSH) levels and older age. A risk-scoring system was calculated by summing the score of these 2 factors (preoperative TSH level and age). The incidences of hypothyroidism were 3, 20, 39, and 70% according to the risk scores of 0, 1, 2 and 3, respectively. Potential risk of postoperative hypothyroidism should be discussed with patients before surgery.

Ultrasonographic features of intrathyroidal parathyroid adenoma causing primary hyperparathyroidism

Preoperative localization study is difficult in patients with primary hyperparathyroidism (PHPT) caused by intrathyroidal parathyroid adenoma. The objective of this study was to evaluate the usefulness of ultrasonography (US) in the diagnosis of intrathyroidal parathyroid adenoma. Between January 2004 and December 2009, seven of 373 patients who underwent parathyroidectomy because of PHPT in our hospital were found to have intrathyroidal parathyroid adenoma. The ultrasonographic features of intrathyroidal parathyroid adenoma were examined retrospectively. The most characteristic feature of intrathyroidal parathyroid adenoma was a hyperechoic line on the ventral surface of the parathyroid gland. A hyperechoic line was clearly detected even in small adenomas in which feeding vessels could not be detected on color Doppler sonography. In comparison with feeding vessels, a hyperechoic line was frequently detected in normally located parathyroid adenoma. (99m)Tc-sestamibi (MIBI) scintigraphy and computed tomography (CT) could show parathyroid adenoma in the intrathyroidal position in only three of five and in only one of three patients examined, respectively. Since a hyperechoic line is characteristic of parathyroid adenoma, an intrathyroidal parathyroid adenoma could be suspected by only non-invasive US.

Serum calcitonin levels with calcium loading tests before and after total thyroidectomy in patients with thyroid diseases other than medullary thyroid carcinoma

Calcitonin is a very sensitive tumor marker of medullary thyroid carcinoma (MTC). Patients with MTC have usually very high levels of serum calcitonin that can be used to diagnose the disease. In order to improve diagnostic sensitivity in family members with small MTCs or to evaluate postoperative biochemical cure status, measurement of calcitonin stimulated with combined intravenous calcium gluconate and pentagastrin has been widely adopted; however, gastrin has become unavailable. Currently, a provocative test using only calcium gluconate is performed; however, the standard values for this test have not been reported. We therefore conducted calcium gluconate stimulation tests in 20 patients before and after total thyroidectomy for thyroid diseases other than MTC. Preoperatively, the mean basal calcitonin level was 24.1 pg/mL and increased to 46.9pg/mL after calcium infusion. The ratio of the peak calcitonin level to the basal value ranged from 1- to 5.23-fold, with a mean of 1.94. The ratio was higher than 3-fold in 3 patients. In 2 patients, peak calcitonin levels exceeded 100 pg/mL. Postoperatively, the mean basal level slightly decreased to 21.15pg/mL and the response to calcium stimulation markedly decreased, with the mean ratio decreasing to 1.1-fold (range, 0.86- to 1.73-fold, maximum peak level, 33 pg/mL). Thus, some subjects without MTC show response to the calcium stimulation test up to 5.24 times the ratio and a peak value of 160 pg/mL, suggesting the requirement for judicious judgment for the early diagnosis of MTC in family members; however, after total thyroidectomy, none of the subjects showed an increase of more than 2-fold or a peak value of 33pg/mL, suggesting that responses greater than 2-fold after MTC surgery might be abnormal, indicating the presence of residual tumor.

Our experience of treatment of cribriform morular variant of papillary thyroid carcinoma; difference in clinicopathological features of FAP-associated and sporadic patients

Cribriform-morular variant (CMV) is a comparably rare histological subtype of papillary thyroid carcinoma (PTC). This can be associated with familial adenomatous polyposis (FAP) due to APC gene mutations. In this study, we investigated the difference in the biological characteristics between FAP-associated and sporadic CMV. Between 1991 and 2010, 32 patients with CMV were treated in Kuma Hospital. Thirty-one of these underwent initial surgery for CMV in Kuma Hospital. Twelve patients were FAP-associated and the remaining 19 were sporadic CMV. All patients were female. Tumors of FAP-associated CMV were more frequently multiple than those of sporadic CMV. Patient age and tumor size did not differ between the two groups. Of 12 FAP-associated CMV, 5 were detected by thyroid nodule (thyroid precedent group) and 7 were detected by FAP (polyposis precedent group) as an initial manifestation. Patient age was younger and tumor size was smaller in the polyposis group than in the thyroid nodule group. All patients lacked extrathyroid extension on intraoperative finding and were node-negative on pathological examination. To date, two patients with FAP-associated CMV who initially underwent hemithyroidectomy (one in Kuma Hospital and one in another hospital) showed recurrence to the remnant thyroid during follow-up. None of the patients showed recurrence to other regions or died of carcinoma. Taken together, CMV is considered an indolent disease in our series. FAP-associated CMV showed multiple tumors more frequently than sporadic CMV. Total thyroidectomy is recommended for FAP-associated CMV, but extensive lymph node dissection is not necessary.

Excellent prognosis of patients with solitary T1N0M0 papillary thyroid carcinoma who underwent thyroidectomy and elective lymph node dissection without radioiodine therapy

BACKGROUND

The extent of surgery for papillary carcinoma significantly differs between western countries and Japan. Almost routine total thyroidectomy with radioiodine ablation therapy has been performed in western countries, whereas limited thyroidectomy has been adopted in Japan, especially for low-risk cases. In this study, the prognosis of patients with solitary papillary carcinoma measuring 2 cm or less without massive extrathyroid extension, clinically apparent lymph node metastasis or distant metastasis at diagnosis (T1N0M0 in the UICC TNM classification) was investigated to elucidate the appropriate extent of surgery for these patients.

METHODS

We investigated the prognosis of 2,638 patients with solitary T1N0M0 papillary carcinoma who underwent initial surgery between 1987 and 2004. Total or near total thyroidectomy was performed for 1,037 patients and the remaining 1,601 patients underwent more limited thyroidectomy. Elective central node dissection was performed for 2,511 patients, accounting for 96%, and 1,545 (59%) also underwent prophylactic lateral node dissection. Radioiodine ablation therapy was performed only for three patients.

RESULTS

The 10-year disease-free survival (DFS) rate of our series was 97%. To date, recurrence was observed in 62 patients (2%) and 41 showed recurrence to the regional lymph nodes. Seventeen of 1,601 patients who received limited thyroidectomy (1%) showed recurrence to the remnant thyroid. Pathological nodal-positive patients showed a worse DFS, but the 10-year DFS rate was still high at 96%. Patients with total or near total thyroidectomy had a better DFS, but the difference disappeared if recurrence to the remnant thyroid was excluded. A number needed to treat (NNT) for total or near total thyroidectomy over hemithyroidectomy was 83 to prevent 1 recurrence.

CONCLUSIONS

These findings suggest that solitary T1N0M0 patients have an excellent prognosis when they undergo thyroidectomy and elective lymph node dissection without radioiodine therapy. Regarding the extent of thyroidectomy, hemithyroidectomy is adequate for these patients, if a 1% risk of recurrence to the remnant thyroid is accepted.

Prognosis and prognostic factors of patients with papillary carcinoma showing distant metastasis at surgery (M1 patients) in Japan

Distant metastasis (DM) at surgery is a prominent prognostic factor in patients with papillary carcinoma of the thyroid. However, the clinical outcomes of these patients (M1 patients) remain unclear. In this study, we investigated the prognosis and prognostic factors of M1 patients. Seventy-one of 5969 patients who underwent initial surgery in Kuma Hospital between 1987 and 2004 were classified as M1 and enrolled in this study. Five-year and 10-year cause specific survival (CSS) rates were 78.8 +/- 5.2% and 76.3 +/- 5.7%, respectively. Patients aged 55 years or older, having tumor larger than 4 cm, massive extrathyroid extension to adjacent organs other than the recurrent laryngeal nerve and cricothyroid or inferior constrictor muscle, and DM to organs other than the lung showed a significantly worse CSS on univariate analysis. On multivariate analysis, the first three parameters were recognized as independent prognostic factors for M1 patients. Patients who underwent locally curative surgery, having DM showing radioactive iodine (RAI) uptake, and who underwent thyroid stimulation hormone (TSH) suppression therapy showed a better CSS rates than those who underwent only palliative surgery, having DM without RAI uptake, and who did not undergo TSH suppression therapy, although there was no significant difference in CSS between these groups. These findings suggest that evaluation of preoperative and intra-operative findings is important to predict the prognosis of M1 patients, the same as that in patients without DM. Locally curative surgery, RAI therapy, and TSH suppression therapy are actively recommended for M1 patients when conditions permit.

Optimal surgical procedure for locally curative surgery in patients with anaplastic thyroid carcinoma: importance of preoperative ultrasonography

Anaplastic thyroid carcinoma (ATC) is a very aggressive disease showing a high mortality. However, long-term survival is expected when patients do not show distant metastasis at diagnosis and undergo locally curative surgery. In this study, we investigated the optimal surgical procedure for locally curative surgery for ATC in a series of 34 patients. Twenty patients underwent total thyroidectomy but there were no detectable skip lesions of ATC in the contralateral lobe on pathological examination. Cause-specific survival (CSS) of Stage IVA or IVB patients who underwent limited thyroidectomy did not differ from that of those who underwent total thyroidectomy. Clinical node metastasis on ultrasonography was not detected in 15 patients but 11 of these patients underwent lymph node dissection. Three of these were node-positive on pathological examination but only one showed metastatic node of ATC that was involved in the primary lesion. Of 19 patients having clinical node metastasis, 10 were ATC node positive on pathological examination. Taken together, for locally curative surgery in ATC patients, 1) total thyroidectomy may not be mandatory unless patients have clinical lesions in the contralateral lobe; 2) prophylactic modified radical neck dissection may not be mandatory for patients who do not demonstrate clinical signs of lymph node metastasis; and 3) extensive and careful therapeutic node dissection may be required for patients demonstrating clinical signs of node metastasis.

Improvement in phonation after reconstruction of the recurrent laryngeal nerve in patients with thyroid cancer invading the nerve

BACKGROUND

We report vocal improvement after reconstruction of the recurrent laryngeal nerve (RLN) in patients with nerve resection, although vocal cord movement was not restored. These methods are not widely recognized.

METHODS

Direct anastomosis, free nerve grafting, or anastomosis to the ansa cervicalis or the vagus nerves with the RLN were performed in 7, 14, 65, and 2 patients with thyroid cancer invading the RLN, respectively. A total of 51 patients had vocal cord paralysis (VCP) pre-operatively. Maximum phonation time (MPT) and vital capacity (VC) were measured before and 1 year after reconstruction. A total of 34 normal subjects and 27 patients with VCP served as controls.

RESULTS

Patients with VCP had significantly shorter MPT values than normal subjects. At 1 year after operation, patients with reconstruction had values of MPT similar to those of normal subjects. Men had significantly longer MPT values than women, but the phonation efficiency index (PEI), defined as the MPT/VC ratio, did not differ by sex. The PEI was significantly less in VCP patients than in normal subjects. Patients with reconstruction achieved PEI values similar to those in normal subjects. Phonation efficiency index values at 1 year after operation was significantly greater than pre-operative PEI and was not affected by the presence or absence of VCP pre-operatively, age, reconstruction method, thickness of suture thread, or use of magnification during the operation.

CONCLUSION

In patients with thyroid cancer requiring RLN resection, RLN reconstruction achieved recovery in phonatory function.