Drawing as a Way of Knowing: How a Mapping Model Assists Preoperative Evaluation of Patients with Thyroid Carcinoma

Background: Effective pre-surgical planning is crucial for achieving successful outcomes in endocrine surgery: it is essential to provide patients with a personalized plan to minimize operative and postoperative risks. Methods: Preoperative lymph node (LN) mapping is a structured high-resolution ultrasonography examination performed in the presence of two endocrinologists and the operating surgeon before intervention to produce a reliable "anatomical guide". Our aim was to propose a preoperative complete model that is non-invasive, avoids overdiagnosis of thyroid microcarcinomas, and reduces medical expenses. Results: The use of 'preoperative echography mapping' has been shown to be successful, particularly in patients with suspected or confirmed neoplastic malignancy. Regarding prognosis, positive outcomes have been observed both post-surgery and in terms of recurrence rates. We collected data on parameters such as biological sex, age, BMI, and results from cytologic tests performed with needle aspiration, and examined whether these parameters predict tumor malignancy or aggressiveness, calculated using a multivariate analysis (MVA). Conclusions: A standard multidisciplinary approach for evaluating neck lymph nodes pre-operation has proven to be an improved diagnostic and preoperative tool.

Peer assisted learning: a meta-ethnographic synthesis of qualitative studies and recommendations for cardiovascular training, practice, and research

INTRODUCTION

Peer assisted learning (PAL) is a common method to complement more traditional teaching. Several systematic reviews and meta-analyses described the most used ways of implementation and showed that it is effective in fostering learning. A synthesis of qualitative data is missing, to highlight the perceived value by the students and to drive a successful implementation.

EVIDENCE ACQUISITION

The search was performed in Pubmed, Scopus and ERIC databases, with a combination of the search strings. The quality of the retrieved articles was assessed through the Critical Appraisal Skills Checklist. The analysis was performed according to the meta-ethnographic method. Fifteen articles were considered for the analysis, saturation was reached after 12 articles.

EVIDENCE SYNTHESIS

Three main themes emerged from the analysis: PAL is effective when implemented in a safe environment, PAL is a driver of development of students' abilities and identity, and the "dark side" of PAL. Nine sub-themes emerged as components of the themes. The final line of argument highlighted the ambivalence of PAL, as an expression of the ambivalence of the still developing professional identity of students.

CONCLUSIONS

This meta-ethnographic synthesis summarizes the elements of success and the threats of PAL, a method that is particularly suitable for the cardiovascular domain. It must be implemented according to some precautions, such as organization and protected time, tutor selection, training and support, a clear integration and endorsement in the framework of the medical curriculum.

How to Manage Advanced Differentiated Thyroid Cancer: Step-by-Step Analysis from Two Italian Tertiary Referral Centers

BACKGROUND

Differentiated thyroid carcinoma (DTC) has an excellent prognosis; however, advanced disease is associated with a worse prognosis and is relatively common. Surgery followed by RAI treatment remains the mainstream treatment for a large majority of patients with high- and intermediate-risk DTC, but its benefits should be carefully weighed against the potential for harm. The aim of this paper is to critically review the experience in treating advanced DTC at two tertiary referral centers in Italy.

METHODS

Retrospective analysis of 300 patients who underwent surgery for ADTC over 30 years.

RESULTS

The complication rate was 50.33%. A total of 135 patients (45%) remained at regular follow-up, 118 (87.4%) were alive, while 17 (12.6%) were deceased. The mean overall survival at 12 years was 84.8% with a mean of 238 months. Eleven patients (8.1%) experienced a relapse after a median of 13 months.

CONCLUSIONS

ADTC patients adequately treated can achieve prolonged survival even in the case of metastasis or disease relapse. Patients with ADTC should be referred to high-volume centers with the availability of an extended multidisciplinary team to receive tailored treatment.

C-Cell Hyperplasia and Cystic Papillary Thyroid Carcinoma in a Patient with Type 1B Pseudohypoparathyroidism and Hypercalcitoninaemia: Case Report and Review of the Literature

Hypercalcitoninaemia has been described in patients with pseudohypoparathyroidism (PHP) type 1A and 1B. Elevated calcitonin levels are thought to result from impaired Gsα receptor signaling, leading to multiple hormone resistance. Evidence on the risk of medullary thyroid carcinoma (MTC) or C-cell hyperplasia in PHP patients with hypercalcitoninaemia is lacking. A 43-year-old Caucasian man was referred to our endocrinology clinic for chronic hypocalcemia associated with elevated serum parathormone levels and a single cystic thyroid nodule. The patient did not show skeletal deformities, and screening for concomitant hormone resistances was negative, except for the presence of elevated serum calcitonin levels. The workup led to a molecular diagnosis of sporadic PHP1B. Fine needle aspiration of the thyroid nodule was not diagnostic. The calcium stimulation test yielded an abnormal calcitonin response. Given the scarcity of data on the risk of thyroid malignancy in PHP and calcium stimulation test results, total thyroidectomy was performed. Histological examination revealed cystic papillary thyroid cancer in a background of diffuse C-cell hyperplasia. To our knowledge, we are the first to describe a rare form of thyroid cancer combined with C-cell hyperplasia in a patient with PHP and hypercalcitoninaemia. In the present case, a mere receptor resistance might not fully explain the elevated calcitonin levels, suggesting that hypercalcitoninaemia should be carefully evaluated in PHP patients, especially in the case of concomitant thyroid nodules. Further studies on larger cohorts are needed to elucidate this topic.

Tumor Inflammatory Microenvironment of the Thyroid Cancer: Relationship between Regulatory T-Cell Imbalance, and p-NFΚB (p65) Expression-A Preliminary Study

BACKGROUND

Inflammatory microenvironment is an essential component of all tumors, including thyroid cancer. Autoimmune thyroid diseases are often associated with thyroid cancer. CD25, expressed in Treg cells and B cells, has been found to be associated with autoimmune thyroid diseases and the NFkB pathway is critical to tumor formation, regulating immune-related genes, and pro-inflammatory cytokine.

METHODS

Protein expression of CD25 and NFkB and its phosphorylated form was analyzed by immunohistochemistry in 80 patients with thyroid cancer (10 cases of cancers with Hashimoto's thyroiditis and 70 cases without).

RESULTS

CD25 was mainly detected in the nucleus of the inflammatory cells such as in the thyrocytes and neoplastic cells. Protein staining was detected in the T-lymphocytes of the outermost zone of the lymphoid follicles. Moreover, in all cancer alterations, there were a higher level of p-NFkB than in the surrounding tissues. Again, p-NFkB staining was evident in neoplastic cells but not evident in inflammatory cells.

CONCLUSIONS

Strong inflammatory infiltrate in the tumor microenvironment is correlated with an invasive phenotype. CD25 and p-NFkB levels were statistically significantly overexpressed in cancer cells.

Parathyroid Retrospective Analysis of Neoplasms Incidence (pTRANI Study): An Italian Multicenter Study on Parathyroid Carcinoma and Atypical Parathyroid Tumour

BACKGROUND

Parathyroid cancer (PC) is a rare sporadic or hereditary malignancy whose histologic features were redefined with the 2022 WHO classification. A total of 24 Italian institutions designed this multicenter study to specify PC incidence, describe its clinical, functional, and imaging characteristics and improve its differentiation from the atypical parathyroid tumour (APT).

METHODS

All relevant information was collected about PC and APT patients treated between 2009 and 2021.

RESULTS

Among 8361 parathyroidectomies, 351 patients (mean age 59.0 ± 14.5; F = 210, 59.8%) were divided into the APT (n = 226, 2.8%) and PC group (n = 125, 1.5%). PC showed significantly higher rates (p < 0.05) of bone involvement, abdominal, and neurological symptoms than APT (48.8% vs. 35.0%, 17.6% vs. 7.1%, 13.6% vs. 5.3%, respectively). Ultrasound (US) diameter >3 cm (30.9% vs. 19.3%, p = 0.049) was significantly more common in the PC. A significantly higher frequency of local recurrences was observed in the PC (8.0% vs. 2.7%, p = 0.022). Mortality due to consequences of cancer or uncontrolled hyperparathyroidism was 3.3%.

CONCLUSIONS

Symptomatic hyperparathyroidism, high PTH and albumin-corrected serum calcium values, and a US diameter >3 cm may be considered features differentiating PC from APT. 2022 WHO criteria did not impact the diagnosis.

Laterocervical lymph node metastases from suspected thyroidal primary site that turned out to be metastases of lung cancer: A case report

Incidental sonographic discovery of thyroid nodules is an increasingly common event in clinical practice. Less frequently, patients with cytological benign thyroid nodules have suspicious cervical lymph nodes detected by ultrasound examination or by cytological exam. Here, we discuss an intriguing case of cervical lymph node metastasis with a probable thyroid origin in a 65-year-old asymptomatic male smoker. He underwent thyroidectomy and unilateral cervical lymphadenectomy. Despite a negative chest X-ray, the postoperative histological examination revealed that the lymph node metastasis was actually from a lung carcinoma. Metastatic lesions in cervical lymph nodes from non-thyroidal origins must be excluded when evaluating lesions in the region, especially when thyroid nodules subjected to fine needle aspiration biopsy yield negative results, or lymph node cytological evaluations are inconsistent with thyroid cytological findings and sonographic features. Thyroid and lung adenocarcinomas share some epithelial and mesenchymal markers. Thyroglobulin helps differentiate primary thyroid tumors from lung ones, but in cases of poor differentiation, distinguishing metastatic lesions in the thyroid gland can be challenging. Lung cancer (LC) is the leading cause of cancer mortality worldwide, and survival rates have only marginally improved over the last several decades. The ongoing clinical challenge is detecting LC at earlier stages of the disease.

The Size of a Thyroid Nodule with ACR TI-RADS Does Not Provide a Better Prediction of the Nature of the Nodule: A Single-Center Retrospective Real-Life Observational Study

We investigated if thyroid nodule size has a predictive value of malignancy on a par with composition, echogenicity, shape, margin, and echogenic foci, and what would be the consequence of observing the rule of the American College of Radiology (ACR) to perform a fine-needle aspiration biopsy (FNAB). We conducted a retrospective real-life observational study on 86 patients who underwent surgery after a standardized diagnostic protocol. We divided the TR3, TR4, and TR5 classes into sub-classes according to the size threshold indicating FNAB (a: up to the threshold for no FNAB; b: over the threshold for FNAB suggested). We computed sensitivity, specificity, and positive (PPV) and negative predictive value (NPV) for the different sub-classes and Youden's index (Y) for the different possible cutoffs. Each sub-class showed the following PPV (0.67, 0.68, 0.70, 0.78, 0.72), NPV (0.56, 0.54, 0.51, 0.52, 0.59), and Y (0.20, 0.20, 0.22, 0.31, 0.30). In this real-life series, we did not find a significant difference in prediction of malignancy between the sub-categories according to the size threshold. All nodules have a pre-evaluation likelihood of being malignant, and the impact and utility of size thresholds may be less clear than suggested by the ACR TIRADS guidelines in patients undergoing standardized thyroid work up.

Quantum Vacuum Excitation of a Quasinormal Mode in an Analog Model of Black Hole Spacetime

Vacuum quantum fluctuations near horizons are known to yield correlated emission by the Hawking effect. We use a driven-dissipative quantum fluid of microcavity polaritons as an analog model of a quantum field theory on a black-hole spacetime and numerically calculate correlated emission. We show that, in addition to the Hawking effect at the sonic horizon, quantum fluctuations may result in a sizable stationary excitation of a quasinormal mode of the field theory. Observable signatures of the excitation of the quasinormal mode are found in the spatial density fluctuations as well as in the spectrum of Hawking emission. This suggests an intrinsic fluctuation-driven mechanism leading to the quantum excitation of quasinormal modes on black hole spacetimes.

A high-resolution neutron spectroscopic camera for the SPARC tokamak based on the Jet European Torus deuterium-tritium experience

Dedicated nuclear diagnostics have been designed, developed, and built within EUROFUSION enhancement programs in the last ten years for installation at the Joint European Torus and capable of operation in high power Deuterium-Tritium (DT) plasmas. The recent DT Experiment campaign, called DTE2, has been successfully carried out in the second half of 2021 and provides a unique opportunity to evaluate the performance of the new nuclear diagnostics and for an understanding of their behavior in the record high 14 MeV neutron yields (up to 4.7 × 10¹⁸ n/s) and total number of neutrons (up to 2 × 10¹⁹ n) achieved on a tokamak. In this work, we will focus on the 14 MeV high resolution neutron spectrometers based on artificial diamonds which, for the first time, have extensively been used to measure 14 MeV DT neutron spectra with unprecedented energy resolution (Full Width at Half Maximum of ≈1% at 14 MeV). The work will describe their long-term stability and operation over the DTE2 campaign as well as their performance as neutron spectrometers in terms of achieved energy resolution and high rate capability. This important experience will be used to outline the concept of a spectroscopic neutron camera for the SPARC tokamak. The proposed neutron camera will be the first one to feature the dual capability to measure (i) the 2.5 and 14 MeV neutron emissivity profile via the conventional neutron detectors based on liquid or plastics scintillators and (ii) the 14 MeV neutron spectral emission via the use of high-resolution diamond-based spectrometers. The new opportunities opened by the spectroscopic neutron camera to measure plasma parameters will be discussed.

Prevalence of Thyroid Nodules and Thyroid Cancer in Individuals with a First-Degree Family History of Non-Medullary Thyroid Cancer: A Cross-Sectional Study Based on Sonographic Screening

Background: The actual rates of suspicious thyroid nodules (TNs) and confirmed thyroid cancer (TC) in putatively "at-risk" selected populations (e.g., individuals with family history of TC) are still uncertain. Methods: Our aim was to explore the prevalence of TC and TN in a cross-sectional study of a consenting population of unaffected individuals (10 years of age or older) with a first-degree relative known to have non-medullary TC (NMTC). Enrolled subjects underwent ultrasonographic studies of the neck between 2009 and 2018. Nodules considered suspicious according to current guidelines were subjected to fine-needle aspiration biopsy (FNAB) for cytology. Results: The screenee population comprised 1176 individuals (median age 42 [26-56] years, 650 females, 55.3%) from 473 kindreds (346 with 1 established NMTC diagnosis at entry, 103 with 2 established NMTC diagnoses, and 24 with 3 or more established NMTC diagnoses at entry). Screening revealed TNs in 500 screenees (42.5%; confidence interval [CI] 39.7-45.4%). Ninety-seven of these (19.4%; CI 16.2-23.1%) underwent FNAB. Only 11 cases of TC were diagnosed in the whole population (0.9%; CI 0.5-1.7%). The prevalence of TC in screenees from kindreds with ≥3 cases (3/24, 12.5%) was higher than that for kindreds with one affected member (6/346, 1.7%; p = 0.01, odds ratio [OR] 7.99; CI 1.21-40.75) and for those with two affected members (2/103, 1.9%; p = 0.05, OR 7.05; CI 0.76-89.44). The prevalence of TNs was 61.8% (CI 56.6-66.8%), 75.7% (CI 66.6-83%), and 66.7% (CI 46.7-82%) in the kindreds with 1, 2, and ≥3 cases, respectively (p = 0.03). Conclusions: On the whole, ultrasound-based screening of unaffected relatives of individuals with established diagnoses of NMTC is likely to reveal a high prevalence of TN and a low prevalence of TC. However, a significantly higher prevalence of TC may be found among screenees from kindreds with at least three established NMTC diagnoses before screening, suggesting that closer surveillance may be warranted in kindreds with this level of familiality.

Oncofertility and Reproductive Counseling in Patients with Breast Cancer: A Retrospective Study

Introduction. Improving the prognosis of breast cancer patients is of utmost importance in terms of increasing survival rates. Modern medicine has therefore prioritized better quality of life for patients, even after the disease, through a better management of the potential long-term side effects induced by anticancer treatments. Fertility preservation and family planning are therefore crucial issues to be addressed in all cancer patients of reproductive age. Along those lines, a new branch of medicine with distinct multidisciplinary characteristics has developed over the years: oncofertility. Although both national and international guidelines value reproductive counseling as an essential aspect of the diagnostic-therapeutic pathway, part and parcel of the informed consent process, it is not included within the protocols adopted by the operating units for the care and management of neoplastic diseases. Objective. This study aimed to evaluate the activity of the Breast Unit of the Policlinico Umberto I Hospital, Rome, Italy, and the degree of compliance with guidelines. By knowing the strengths and weaknesses of such approaches, the standards of care offered to breast cancer patients can be improved. Materials and methods. A retrospective study based on a review of medical records was conducted between 2014 and 2021. Patients under 40 years of age diagnosed with non-metastatic malignancies were included who received chemotherapy treatment, namely neoadjuvant, adjuvant or adjuvant hormone therapy. Results. The data were extracted from the medical records of 51 patients who met the inclusion criteria, 41% of whom received reproductive counseling, and of these, 43% decided to undertake a path of fertility preservation. Factors such as the absence of children and young age reportedly favored both the interest in counseling proposals by the medical staff and the decision to undertake a path of fertility preservation. Conclusions. The study shows that there has been growing interest in the topic of oncofertility, especially in light of law 219/2017. Therefore, since 2018, multiple proposals for reproductive counseling have been set forth, but there was not an equally growing demand for fertility preservation practices, which can be explained by the invasive nature of such practices, the patients’ concern about their own state of health, and poor or inadequate information. Such impediments highlight the importance of standardized counseling and the need for a multidisciplinary medical team to support the patient in the decision-making process. The study also revealed a drop in the number of patients receiving counseling due to the COVID-19 pandemic, contrary to the positive trend that was recorded prior to the pandemic.

Analysis of serum microRNA in exosomal vehicles of papillary thyroid cancer

PURPOSE

In this study, we investigated the profile of microRNAs (miRNAs) contained in exosomes secreted in the serum of patients with papillary thyroid cancer (PTC).

METHODS

Exosome were isolated by adding ExoQuick Exosome Precipitation Solution. Dynamic light scattering (DLS) and western blotting analysis were used to ensure the quality of exosomes. The expression levels of miRNAs were investigated using custom-designed TaqMan Advanced miRNA Array Cards in the screening cohort and using specific TaqMan Advanced MicroRNA Assays in the validation cohort.

RESULTS

We identified miR24-3p, miR146a-5p, miR181a-5p and miR382-5p with different expression levels in two different series of 56 and 58 PTC patients as compared with healthy controls. Significant differences in the expression of three PTC exosomal miRNAs, depending on the presence of lymph node metastasis, were detected in only one PTC series. When comparing the expression levels of some PTC-specific exosomal miRNAs with those of the same miRNAs circulating free of any encapsulation, we found a significant correlation for only miR24-3p, suggesting that only select miRNAs are secreted in exosomes.

CONCLUSIONS

Our findings demonstrate that four miRNAs are differently secreted in the exosomes of PTC patients, whereas no conclusive results were found to characterize PTCs with lymph node metastasis, suggesting caution in the use of circulating exosomal miRNA expression levels as lymph node metastasis biomarkers. Further investigation into the mechanisms governing miRNA secretion in tumor cells are required.

Preoperative Ultrasonography in the Evaluation of Suspected Familial Non-Medullary Thyroid Cancer: Are We Able to Predict Multifocality and Extrathyroidal Extension?

Family history of thyroid cancer increases the risk of harboring thyroid malignancies that end up having extrathyroidal extension (ETE) and multifocality on histology; some authors suggest a more aggressive surgical approach. Their pre-operative identification could allow more conservative surgical procedures if none of these features are suspected. Our aim was to assess if neck ultrasonography could identify or exclude multifocality or ETE in these patients to tailor the extent of surgery. This retrospective study included patients with previous thyroid surgery, ≥1 first-grade relative with thyroid cancer, and who had undergone pre-surgical ultrasound. ETE was suspected in the case of thyroid border interruption or gross invasion of perithyroidal tissues. Multiple suspicious nodules were defined as suspicion of multifocal cancer. The cohort consisted of 45 patients (median age 49 years, 40 with thyroid cancer, 30 females). The positive predictive value of ultrasonography in predicting multifocality and ETE was 57.14% (25.25–84.03) and 41.67% (21.5–65.1%), respectively, while the negative predictive values were 63.2% (56.4–69.4%) and 72.7% (63.3–80.5%). Pre-operative ultrasound examination is unable to reliably identify or exclude multifocal disease or extrathyroidal extension. In patients scheduled for surgery and with a first-degree relative affected by DTC, a “negative” pre-operative US report does not exclude the potential finding of multifocality and ETE at final histopathology.

Poorly Differentiated Thyroid Carcinoma: Single Centre Experience and Review of the Literature

There is controversy in the literature regarding a distinct subset of thyroid carcinoma whose histologically classification falls between well-differentiated and anaplastic carcinomas, previously identified as ‘poorly differentiated thyroid carcinoma’ (PDTC), or ‘insular carcinoma’, in view of the peculiar morphological characteristics of the cell groupings. The correct diagnosis and treatment of this entity have important prognostic and therapeutic significance. In this review, we describe the epidemiology, diagnosis, and management of PDTC and report our single centre experience to add to the limited evidence existing in the literature.

Forward modeling of pile-up events in liquid scintillator detectors for neutron emission spectroscopy

When using liquid scintillator detectors to measure the neutron emission spectrum from fusion plasmas, the problem of pile-up distortion can be significant. Because of the large neutron rates encountered in many fusion experiments, some pile-up distortion can remain even after applying traditional pile-up elimination methods, which alters the shape of the measured light-yield spectrum and influences the spectroscopic analysis. Particularly, pile-up events appear as a high-energy tail in the measured light-yield spectrum, which obfuscates the contribution that supra-thermal ions make to the energy spectrum. It is important to understand the behavior of such "fast ions" in fusion plasmas, and it is hence desirable to be able to measure their contribution to the neutron spectrum as accurately as possible. This paper presents a technique for incorporating distortion from undetected pile-up events into the analysis of the light-yield spectrum, hence compensating for pile-up distortion. The spectral contribution from undetected pile-up events is determined using Monte Carlo methods and is included in the spectroscopic study as a pile-up component. The method is applied to data from an NE213 scintillator detector at JET and validated by comparing with results from the time-of-flight spectrometer TOFOR, which is not susceptible to pile-up distortion. Based on the results, we conclude that the suggested analysis method helps counteract the problem of pile-up effects and improves the possibilities for extracting accurate fast-ion information from the light-yield spectrum.

First spatially resolved measurements of the D-3He α-particle source with the upgraded JET gamma-ray camera

The Joint European Torus (JET) gamma-ray camera has been recently upgraded with the installation of new gamma-ray detectors, based on LaBr₃(Ce) scintillation crystals, which add spectroscopic capability to the existing system allowing measurements with good energy resolution (5% at 0.622 MeV), a dynamic range from hundreds of keV up to about 30 MeV, and high counting rate capabilities of MCps. First gamma-ray measurements during the C38 campaign of the JET have been successfully carried out, in particular, in D-³He plasmas from three-ion ion cyclotron resonance heating experiments, where the detection of 16.4 MeV γ-rays from D + ³He → γ + ⁵Li reactions with the gamma-ray camera upgrade allowed determining the spatial profile of alpha particles born in D + ³He fusion reactions.

Novel compact hard x-ray spectrometer with MCps counting rate capabilities for runaway electron measurements on DIII-D

A novel compact spectrometer optimized for the measurement of hard x rays generated by runaway electrons is presented. The detector is designed to be installed in the fan-shaped collimator of the gamma-ray imager diagnostic at the DIII-D tokamak. The spectrometer is based on a 1 × 1 cm² cerium doped yttrium aluminum perovskite scintillator crystal coupled with a silicon photomultiplier. The detector dynamic energy range is in excess of 10 MeV, with an energy resolution of ∼10% at 661.7 keV. The fast detector signal (≈70 ns full width at half maximum) allows for operation at counting rates in excess of 1 MCps. The gain stability of the system can be monitored in real time using a light-emitting diode embedded in the instrument. The detector is expected to be deployed in the forthcoming DIII-D runaway electron experimental campaign.

A new tangential gamma-ray spectrometer for fast ion measurements in deuterium and deuterium-tritium plasmas of the Joint European Torus

A new tangential gamma-ray spectrometer has been developed for fast ion measurements in deuterium and deuterium-tritium plasmas of the Joint European Torus (JET). The instrument is based on a LaBr₃ crystal with a photo-multiplier tube and replaces a pre-existing bismuth germanate detector, providing enhanced energy resolution and a counting rate capability in the MHz range. The line of sight is equipped with a LiH attenuator, which reduces the background due to 14 MeV neutron interactions with the crystal by more than two orders of magnitude and enables the observation of gamma-ray emission from confined α particles in JET deuterium-tritium plasmas. Thanks to its tangential line of sight, the detector can distinguish co- and counter-passing ions. The performance of the instrument is demonstrated through the results of recent JET fast ion experiments in deuterium plasmas.

Selective Use of Radioactive Iodine Therapy for Papillary Thyroid Cancers With Low or Lower-Intermediate Recurrence Risk

CONTEXT

Current guidelines recommend a selective use of radioiodine treatment (RAI) for papillary thyroid cancer (PTC).

OBJECTIVE

This work aimed to determine how policy changes affect the use of RAI and the short-term outcomes of patients.

METHODS

A retrospective analysis of longitudinal data was conducted in an academic referral center of patients with nonaggressive PTC variants; no extrathyroidal invasion or limited to soft tissues, no distant metastases, and 5 or fewer central-compartment cervical lymph node metastases. In cohort 1, standard treatments were total thyroidectomy and RAI (May 2005-June 2011); in cohort 2 decisions on RAI were deferred for approximately 12 months after surgery (July 2011-December 2018). Propensity score matching was used to adjust for sex, age, tumor size, lymph node status, and extrathyroidal extension. Intervention included immediate RAI or deferred choice. Main outcome measures were responses to initial treatment during 3 or more years of follow-up.

RESULTS

In cohort 1, RAI was performed in 50 of 116 patients (51.7%), whereas in cohort 2, it was far less frequent: immediately in 10 of 156 (6.4%), and in 3 more patients after the first follow-up data. The frequencies of structural incomplete response were low (1%-3%), and there were no differences between the 2 cohorts at any follow-up visit. Cohort 2 patients had higher rates of "gray-zone responses" (biochemical incomplete or indeterminate response).

CONCLUSION

Selective use of RAI increases the rate of patients with "uncertain" status during early follow-up. The rate of structural incomplete responses remains low regardless of whether RAI is used immediately. Patients should be made aware of the advantages and drawbacks of omitting RAI.

New method for time alignment and time calibration of the TOFOR time-of-flight neutron spectrometer at JET

The TOFOR time-of-flight (TOF) neutron spectrometer at the Joint European Torus (JET) is composed of 5 start (S1) and 32 stop (S2) scintillation detectors. Recently, the data acquisition system (DAQ) of TOFOR was upgraded to equip each of the 37 detectors with its own waveform digitizer to allow for correlated time and pulse height analysis of the acquired data. Due to varying cable lengths and different pulse processing pathways in the new DAQ system, the 160 (5 · 32) different TOF pairs of start-stop detectors must be time-aligned to enable the proper construction of a summed TOF spectrum. Given the time (energy) resolution required by the entire spectrometer system to measure different plasma neutron emission components, it is of importance to align the detector pairs to each other with sub-nanosecond precision. Previously, the alignment partially depended on using fusion neutron data from Ohmic heating phases of JET experimental pulses. The dependence on fusion neutron data in the time alignment process is, however, unsatisfactory as it involves data one would wish to include in an independent analysis for physics results. In this work, we describe a method of time-aligning the detector pairs by using gamma rays. Given the known geometry and response of TOFOR to gamma rays, the time alignment of the detector pairs is found by examining gamma events interacting in coincidence in both S1-S1 and S1-S2 detector combinations. Furthermore, a technique for separating neutron and gamma events in the different detector sets is presented. Finally, the time-aligned system is used to analyze neutron data from Ohmic phases for different plasma conditions and to estimate the Ohmic fuel ion temperature.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Diagnostic Performance of Neck Ultrasonography in the Preoperative Evaluation for Extrathyroidal Extension of Suspicious Thyroid Nodules

BACKGROUND

A preoperative neck ultrasound (US) is recommended for all patients with suspected thyroid cancer, to identify features potentially changing surgical extent. The extrathyroidal extension (ETE) is considered an indication for total thyroidectomy, but there is limited consensus on its US definition, and the interobserver reliability is low. This study aimed to evaluate the predictive value of neck US for ETE before surgery and to estimate the diagnostic performance of different US findings, evaluated during real-time examinations.

METHODS

Patients referred to surgery between November 1, 2015, and May 31, 2019, for a suspicious thyroid cancer underwent a preoperative neck US, with systematic assessment for ETE. Three definitions were tested: very restrictive (capsular disruption with suspicious images of surrounding tissues invasion), restrictive (including also capsular abutment with evidence of capsular disruption), and nonrestrictive (capsular abutment is sufficient). Histopathology report of ETE involving at least soft tissues was considered positive. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

RESULTS

The study cohort included 128 patients, with 102 (79.7%) confirmed malignancies, and 44 (43.1%) histological ETE. The nonrestrictive definition had good sensitivity (86.4%) but low specificity (29.8%), with an NPV of 80.6%; the restrictive definition had higher specificity (81%), while the very restrictive had specificity and PPV of 100%.

CONCLUSIONS

A more extensive surgical approach should not be based on US suspicion of ETE alone, with the possible exception of gross invasion appearance. The absence of any sign of ETE, on the other hand, has a substantial negative predictive value.

Cancer Care During COVID-19 Era: The Quality of Life of Patients With Thyroid Malignancies

Background: The Covid-19 pandemic's potential psychological impact has been widely discussed on the basis of expert opinion and previous experience with emergencies of this type. We conducted a survey of cancer patients to explore more objectively the outbreak's impact on their emotional well-being and quality of life.

Methods: Between March 18 and April 4, 2020, at an endocrine cancer center in Rome, Italy, 137 patients were asked to complete an online 6-item questionnaire developed by our staff to explore the emotional effects of the Covid-19 outbreak in Italy (Covid-19 Emotional Impact Survey, C-19EIS). For validation purposes, we also asked participants to complete an online version of the validated Italian translation of the EORTC QLQ-C30 questionnaire. Responses were analyzed in relation to responders' age, sex, and clinical status (advanced/metastatic disease undergoing systemic treatment vs. stable metastatic thyroid cancer in active surveillance vs. low-risk thyroid cancers with no evidence of structural disease during standard follow-up).

Results: Response rates were high (51% for the C-19EIS, 44.5% for the EORTC QLQ-C30). Overall C-19EIS scores indicated high concern over the outbreak (median 8/12). Scores were higher in women (8 [IQR 5–9] vs. 6 [IQR 5–8] in men; p = 0.048) and in patients <65 years (8 [IQR 5–9] vs. 6 [IQR 4–8] in older patients; p = 0.013). No differences emerged across clinical status groups. C-19EIS scores were inversely correlated with the EORTC QLQ-C30 Emotional function subscale (rho −0.69; p < 0.001).

Conclusions: There is objective evidence that the Covid-19 outbreak is causing substantial emotional distress among cancer patients, regardless of their disease severity or current health-care needs.

Nipple-Sparing Mastectomy Long-Term Outcomes: Early and Late Complications

Background and Objectives: The surgical choice treatment of the breast cancer mostly depends on the stage of the disease. In the last years, breast cancer surgery has moved from being destructive to being more respectful of the anatomical and physiological integrity of the gland. The aim of the breast surgery should be finalized to obtain the best aesthetic and functional results, respecting the principles of oncologic radicality. The present study is a retrospective analysis aimed to evaluate the long-term outcomes of a conservative technique like the nipple-sparing mastectomy. Materials and Methods: We observed 894 patients with a median age of 47.5 years old, underwent nipple-sparing mastectomy between 2002–2017. The data acquired include population and tumor characteristics, patient reconstructive outcomes, including locoregional, regional, and distant metastases; other variables, among nipple–areola complex necrosis and infection were collected. Results: The complications detected were considered as “early” within 1 month later the nipple-sparing mastectomy or “late” after this time. The overall complications rate (early and late) and the overall survival and the relapses detected by this study were comparable with those reported in the literature. In order to identify factors that correlate with complications, either early or later, it has been processed an evaluation of the univariate analysis showing adjuvant chemotherapy as the only predictive factor for late complications, while we encountered no predictors for early complications. Conclusions: The present study adds to the data already present in literature, demonstrating that the nipple-sparing mastectomy is a safe procedure, providing good oncological and aesthetic results in patients carefully selected.

Development of gamma ray spectrometer with high energy and time resolutions on EAST tokamak

A new gamma ray spectrometer with high energy and time resolutions has been developed and installed on the EAST tokamak to study fast ion and runaway electron behaviors. The spectrometer is based on a LaBr₃(Ce) scintillator detector and a fully digital data acquisition system that is based on a digitizer with digital pulse processing algorithms. The energy resolution of the spectrometer is about 3.9% at 662 keV, and the spectrometer can operate stably at a counting rate as high as 1 MHz, monitored by using a light emitting diode monitoring system. The measured gamma ray spectrum is simulated based on Geant4 and unfolded with the high-resolution boosted Gold deconvolution algorithm, aiming at reconstructing the energy distribution functions of fast ions and runaway electrons.

Interaction study between antiplatelet agents, anticoagulants, thyroid replacement therapy and a bioavailable formulation of curcumin (Meriva®)

OBJECTIVE

The objective of this clinical study is to evaluate possible interactions between antiplatelet agents, anticoagulants, thyroid hormone replacement therapy and a formulation of curcumin (Meriva®) that resulted effective for the complementary treatment of osteoarthritis.

PATIENTS AND METHODS

Interaction between antiplatelet agents and Meriva® was evaluated by measuring anti-platelet activity with the in-vivo bleeding-time (BT) in patients assuming acetylsalicylic acid or ticlopidine or clopidogrel from at least 2 years. The BT was evaluated before and after 10 days of supplementation with Meriva®. The interaction between anticoagulants and Meriva® was evaluated in patients using warfarin or dabigatran for previous venous thrombosis. The INR level was evaluated before and after 10 days of supplementation with the curcumin formulation. Thyroid function tests in hypothyroid patients using LT4 replacement therapy (Eutirox®) were evaluated before and after 15 days of supplementation with Meriva®. Similarly, levels of glycemia and glycated hemoglobin were evaluated in diabetic patients in treatment with metformin, before and after 10 days of supplementation with the studied product.

RESULTS

After 10 days of supplementation with Meriva® the average BT value was not significantly different for patients assuming acetylsalicylic acid, ticlopidine or clopidogrel at standard dosages. Similarly, after 10 days of Meriva® treatment, the INR level in the two groups of patients assuming warfarin or dabigatran was not statistically different from that observed at baseline. In the analyzed patients assuming LT4 or metformin, no interactions between the therapy and Meriva® were observed.

CONCLUSIONS

Results from this non-interaction clinical study suggest that Meriva® does not interfere with the antiplatelet activity of the most common antiplatelet agents nor alters the INR values in stable patients assuming warfarin or dabigatran. Similarly, dosages of LT4 or metformin do not need to be adjusted in case of complementary treatment with Meriva®.

Thyroid Cancer Patients With No Evidence of Disease: The Need for Repeat Neck Ultrasound

CONTEXT

Ultrasonography (US) is considered the most sensitive tool for imaging persistent or recurrent papillary thyroid cancer (PTC) in the neck.

OBJECTIVE

To clarify the usefulness of routine neck US in low- and intermediate-risk patients with PTC with no evidence of disease 1 year after thyroidectomy.

DESIGN

Retrospective analysis of prospectively recorded data.

SETTING

Academic center.

PATIENTS

Two hundred twenty-six patients with PTC with sonographically normal neck lymph nodes and unstimulated serum thyroglobulin (Tg) levels that were either undetectable (<0.20 ng/mL) or low (0.21 to 0.99 ng/mL) at the 1-year evaluation.

INTERVENTIONS

Yearly assessment: unstimulated serum Tg level, anti-Tg-antibody (TgAb) titer, TSH levels, and ultrasound examination of neck lymph nodes.

MAIN OUTCOME MEASURES

Rates of ultrasonographic lymph node abnormalities at the 3-year and last follow-up visits.

RESULTS

In patients with an undetectable Tg level at the 1-year evaluation, sonographically suspicious neck lymph nodes were found in 1.2% of patients at 3 years and in 1.8% at the last visit [negative predictive values (NPVs) of 1-year Tg < 0.2 ng/mL: 98.8% (95% CI 95.8% to 99.9%) and 98.2% (95% to 99.6%), respectively]. Similar NPVs emerged for low detectable 1-year Tg levels [98.2% (90.3% to 99.9%) and 94.5% (84.9% to 98.9%) at the 3-year and last visits, respectively]. Seventy-five percent of the nodal lesions were likely false positive; none required treatment.

CONCLUSIONS

Low- and intermediate-risk patients with PTC with negative ultrasound findings and unstimulated Tg levels <1 ng/mL at the 1-year evaluation can be safely followed with clinical assessments and unstimulated serum Tg determinations. Neck US might be repeated if TgAb titers rise, or unstimulated Tg levels exceed 1 ng/mL.

The surgical management of locally advanced well-differentiated thyroid carcinoma: changes over the years according to the AJCC 8th edition Cancer Staging Manual

Background

Well-differentiated thyroid carcinoma is defined as locally advanced in the presence of an extra thyroid extension, e.g., when the surrounding structures such as the trachea, larynx, esophagus and main blood vessels are invaded by cancer. The 8th edition AJCC Cancer Staging Manual states that this is the main characteristic to evaluate for the staging and consequently for the prognosis in patients over 55 years old.

Main body

Distinguishing different forms of locally advanced thyroid cancer is essential, and the various anatomical structures and the clinical and therapeutic consequences must be taken into account. An accurate diagnosis of the organs invaded by thyroid cancer is necessary for the planning of surgical treatment, and both aspects are crucial to improving the patients’ survival. Patients affected by thyroid cancer with extra thyroid extension have a poor prognosis and the removal of the entire neoplasm represents a key factor for better disease-free survival.

Conclusions

We discuss the changes introduced by the 8th edition AJCC Cancer Staging Manual, in terms of the diagnostic and surgical management of extra thyroid extension, in patients affected by papillary and follicular thyroid cancer.

Oral administration of a curcumin-phospholipid formulation (Meriva®) for treatment of chronic diabetic macular edema: a pilot study

OBJECTIVE

The purpose of this open-label study was to investigate the effect of a curcumin-phospholipid lecithin formulation (Meriva®) on visual acuity and optical coherence tomography (OCT) retinal thickness in patients with chronic diabetic macular edema.

PATIENTS AND METHODS

Curcumin-phospholipid lecithin formulation (Meriva®, Indena S.p.A, Milan, Italy) was administered as tablets (Norflo®, Eye Pharma, Genoa, Italy) twice a day. Visual acuity and macular edema as measured by OCT before and after curcumin-phospholipid formulation treatment were assessed.

RESULTS

The study included 12 eyes from 11 patients who completed at least a 3-month follow-up period. After 3 months of therapy, no eyes showed reduction in visual acuity, 16% showed stabilization, and 84% showed improvement. The improvement was statistically significant (p = 0.0072). After 3 months of therapy, 92% of eyes showed reduction of macula edema, 8% showed stabilization, and 0% showed an increase (p = 0.009).

CONCLUSIONS

Our results, albeit preliminary, suggest that a curcumin-phospholipid formulation (Meriva®), administered as Norflo® tablets, may be feasible in the improvement of visual acuity and reduction of macular edema in patients with diabetic retinopathy.

Optimization of MAXED input parameters with applications to the unfolding of neutron diagnostics data from the Joint European Torus

Organic NE213 liquid scintillator neutron detectors are commonly used at accelerator facilities for neutron beam diagnostics. In recent years, they have also been installed at nuclear fusion facilities to measure the neutron energy spectra from Deuterium (D) and Deuterium-Tritium plasmas, e.g., at the ASDEX Upgrade (Garching, Germany) and at the Joint European Torus (JET, Culham, UK). The NE213 equivalent scintillating material (now BC501A) of the detector is sensitive to neutron and gamma radiation, so pulse discrimination techniques are applied in order to obtain the measured neutron pulse height spectrum (PHS). If the neutron detector is stable, controlled, and well-characterized (i.e., its response function to incoming neutrons of known energy is determined with high accuracy), it can be used as a neutron spectrometer. The measured PHS can then be analyzed using standard techniques such as unfolding to determine the incoming neutron energy spectrum. This article focuses on the unfolding of neutron data measured in D plasma experiments at JET by a compact broadband neutron spectrometer using the maximum entropy unfolding code MAXED. A general method for optimizing MAXED input parameters is described and applied to the measured PHS to diagnose the effects of the auxiliary heating of JET D plasma on the neutron energy spectra.

Absorption, metabolism and protective role of fruits and vegetables polyphenols against gastric cancer

Growing evidence links free radicals to the aging processes, degenerative diseases and cancer, underlying the important role played by some antioxidants, as polyphenols, present in fruits and vegetables, which seem able to counteract the toxic effects induced by oxidative stress. The gastrointestinal tract is continuously exposed to oxidant and antioxidant substances and, in particular in this district, the food rich in antioxidants could exert a protective effect against the risk of cancer. Polyphenols have a direct protective effect on the gastrointestinal tract, detoxifying the Reactive Oxygen Species (ROS) and Reactive Nitrogen Species (RNS), preserving antioxidant proteins and complexing metals. Although polyphenols are a class of antioxidant largely represented in vegetables and fruits, we are still uncertain whether the beneficial effects of a diet rich in plant products, are mainly due to these compounds. Our knowledge does not allow to be sure about which antioxidants are capable of having therapeutic effects, through which mechanism, the exact therapeutic dose or how long they have to be taken to have a significant protective effect. In this review we take into account the most common antioxidants, usually found in the diet and the processes regulating their absorption, metabolism and excretion, in order to elucidate the mechanism that could be responsible for the protection against cancer.

Prospective Evaluation of Semiquantitative Strain Ratio and Quantitative 2D Ultrasound Shear Wave Elastography (SWE) in Association with TIRADS Classification for Thyroid Nodule Characterization

PURPOSE

 To evaluate the diagnostic performance of strain ratio elastography (SRE) and shear wave elastography (SWE) alone and in combination with Thyroid Imaging Reporting and Data System (TIRADS) classification parameters to improve differentiation between benign and malignant thyroid nodules.

MATERIALS AND METHODS

 In this prospective study benign (n = 191) and malignant (n = 52) thyroid nodules were examined with high-resolution ultrasound (US) features using the TIRADS lexicon and SRE semiquantitative and SWE quantitative findings using histology or cytology as the gold standard with a 12-month follow-up. Sensitivity (Se), specificity (Sp) and the area under the ROC curve (AUROC) were used to evaluate the diagnostic performance of each feature and combinations of the methods.

RESULTS

 TIRADS score showed a sensitivity of 59.6 %, a specificity of 83.8 % with an AUROC of 0.717, a PPV of 50.0 % and an NPV of 88.4 %. SRE yielded the highest performance with a sensitivity of 82.7 %, a specificity of 92.7 % with AUROC of 0.877, a PPV 75.4 % and an NPV of 95.2 %. SWE (kPa) had a sensitivity and specificity of 67.3 % and 82.7 %, respectively, with an AUROC of 0.750, a PPV of 51.5 % and an NPV of 90.3 %. Differences were significant for SRE only but not for SWE.

CONCLUSION

 Ultrasound elastography may improve thyroid nodule discrimination. In particular, SRE has a better performance than TIRADS classification, while their combination improves sensitivity.

PD-1 Ligand Expression in Epithelial Thyroid Cancers: Potential Clinical Implications

The new immunotherapy targeting the programmed cell death 1 (PD-1) receptor and its cognate ligand PD-L1 has renewed hopes of eradicating the most difficult human cancers to treat. Among these, there are the poorly differentiated and anaplastic thyroid cancers, unresponsive to all the therapies currently in use. In the present review we will summarize information regarding the expression of PD-L1 in the different thyroid cancer histotypes, its correlation with clinicopathological features, and its potential prognostic value. Then, we will evaluate the available data indicating the PD-1/PD-L1 axis as a promising target for thyroid cancer therapy.

Reducing the Number of Unnecessary Thyroid Biopsies While Improving Diagnostic Accuracy: Toward the "Right" TIRADS

CONTEXT

The prevalence of thyroid nodules in the general population is increasingly high, and at least half of those biopsied prove to be benign. Sonographic risk-stratification systems are being proposed as "rule-out" tests that can identify nodules that do not require fine-needle aspiration (FNA) cytology.

OBJECTIVE

To comparatively assess the performances of five internationally endorsed sonographic classification systems [those of the American Thyroid Association, the American Association of Clinical Endocrinologists, the American College of Radiology (ACR), the European Thyroid Association, and the Korean Society of Thyroid Radiology] in identifying nodules whose FNAs can be safely deferred and to estimate their negative predictive values (NPVs).

DESIGN

Prospective study of thyroid nodules referred for FNA.

SETTING

Single academic referral center.

PATIENTS

Four hundred seventy-seven patients (358 females, 75.2%); mean (SD) age, 55.9 (13.9) years.

MAIN OUTCOME MEASURES

Number of biopsies classified as unnecessary, false-negative rate (FNR), sensitivity, specificity, predictive values, and diagnostic ORs for each system.

RESULTS

Application of the systems' FNA criteria would have reduced the number of biopsies performed by 17.1% to 53.4%. The ACR Thyroid Imaging Reporting and Data System (TIRADS) allowed the largest reduction (268 of 502) with the lowest FNR (NPV, 97.8%; 95% CI, 95.2% to 99.2%). Except for the Korean Society of Thyroid Radiology TIRADS, all other systems exhibited significant discriminatory performance but produced significantly smaller reductions in the number of procedures.

CONCLUSIONS

Internationally endorsed sonographic risk stratification systems vary widely in their ability to reduce the number of unnecessary thyroid nodule FNAs. The ACR TIRADS outperformed the others, classifying more than half the biopsies as unnecessary with a FNR of 2.2%.

Lack of association between obesity and aggressiveness of differentiated thyroid cancer

PURPOSE

Aim of this study was to evaluate the association between body mass index (BMI) and aggressive features of differentiated thyroid cancer (DTC) in a prospective cohort.

METHODS

Patients with DTC were prospectively enrolled at a tertiary referral center and grouped according to their BMI. Aggressive clinic-pathological features were analyzed following the American Thyroid Association Initial Risk Stratification System score.

RESULTS

The cohort was composed of 432 patients: 5 (1.2%) were underweight, 187 (43.3%) normal weight, 154 (35.6%) overweight, 68 (15.7%) grade 1 obese, 11 (2.5%) grade 2 obese and 7 (1.6%) grade 3 obese. No single feature of advanced thyroid cancer was more frequent in obese patients than in others. No significant correlation was found between BMI, primary tumor size (Spearman's ρ - 0.02; p = 0.71) and ATA Initial Risk Stratification System score (ρ 0.03; p = 0.49), after adjustment for age. According to the multivariate logistic regression analysis, male gender and pre-surgical diagnosis of cancer were significant predictors of cancer with high or intermediate-high recurrence risk according to the ATA system (OR 2.06 and 2.51, respectively), while older age at diagnosis was a protective factor (OR 0.98), and BMI was not a predictor. BMI was a predictor of microscopic extrathyroidal extension only (OR 1.06).

CONCLUSIONS

Obesity was not associated with aggressive features in this prospective, European cohort of patients with DTC.

Thyroid diseases and skin autoimmunity

The skin is the largest organ of the body, at the boundary with the outside environment. Primarily, it provides a physical and chemical barrier against external insults, but it can act also as immune organ because it contains a whole host of immune-competent cells of both the innate and the adaptive immune systems, which cooperate in eliminating invading pathogens following tissue injury. On the other hand, improper skin immune responses lead to autoimmune skin diseases (AISD), such as pemphigus, bullous pemphigoid, vitiligo, and alopecia. Although the interplay among genetic, epigenetic, and environmental factors has been shown to play a major role in AISD etiology and progression, the molecular mechanisms underlying disease development are far from being fully elucidated. In this context, epidemiological studies aimed at defining the association of different AISD with other autoimmune pathologies revealed possible shared molecular mechanism(s) responsible for disease progression. In particular, over the last decades, a number of reports have highlighted a significant association between thyroid diseases (TD), mainly autoimmune ones (AITD), and AISD. Here, we will recapitulate the epidemiology, clinical manifestations, and pathogenesis of the main AISD, and we will summarize the epidemiological evidence showing the associations with TD as well as possible molecular mechanism(s) underlying TD and AISD pathological manifestations.

Thyroid nodule recurrence following lobo-isthmectomy: incidence, patient's characteristics, and risk factors

PURPOSE

This study was aimed at assessing the incidence and timing of thyroid nodules recurrence, defined as appearance of new benign or malignant nodules in contralateral lobe in patients with benign thyroid nodules or thyroid microcarcinoma treated with lobo-isthmectomy. Patient's characteristics and risk factors associated with this phenomenon were also investigated.

METHODS

A retrospective study was performed by evaluating 413 patients undergoing lobo-isthmectomy with a minimum follow-up of 1 year. Clinical characteristics, surgical interventions and complications, histological diagnosis, and thyroid function at last follow-up were collected.

RESULTS

Single or multiple thyroid nodule recurrence equally occurred in 80 patients (23%) with a median time to relapse of ~ 5 years (range 0.3-34.5 years) after lobo-isthmectomy. Recurrence was significantly associated with younger age (< 46 years) and number of pregnancies in women. Development of hypothyroidism was not rare either (~ 10%) and appeared in 3-19 months; a preoperative TSH level > 2.43 mIU/L was associated with the need of l-thyroxin replacement therapy after surgery. The most frequent surgical complication was transient hypoparathyroidism (4.6%), while the rate of permanent hypoparathyroidism significantly increased in patients submitted to completion thyroidectomy (5.3%).

CONCLUSIONS

Thyroid nodules recurrence following lobo-isthmectomy is not a rare event and occurs within 5 years after surgery, more frequently in younger patients with family history of nodular goiter and in women with multiple pregnancies. Pre-surgical TSH levels may predict the development of post-surgical hypothyroidism, possibly improving the management of patients addressed to surgery.

Is thyroid nodule location associated with malignancy risk?

Purpose

Nodules located in the upper pole of the thyroid may carry a greater risk for malignancy than those in the lower pole. We conducted a study to analyze the risk of malignancy of nodules depending on location.

Methods

The records of patients undergoing thyroid-nodule fine-needle aspiration cytology (FNAC) at an academic thyroid cancer unit were prospectively collected. The nodules were considered benign in cases of a benign histology or cytology report, and malignant in cases of malignant histology. Pathological findings were analyzed based on the anatomical location of the nodules, which were also scored according to five ultrasonographic classification systems.

Results

Between November 1, 2015 and May 30, 2018, 832 nodules underwent FNAC, of which 557 had a definitive diagnosis. The prevalence of malignancy was not significantly different in the isthmus, right, or left lobe. Among the 227 nodules that had a precise longitudinal location noted (from 219 patients [155 females], aged 56.2±14.0 years), malignancy was more frequent in the middle lobe (13.2%; odds ratio [OR], 9.74; 95% confidence interval [CI], 1.95 to 48.59). This figure was confirmed in multivariate analyses that took into account nodule composition and the Thyroid Imaging, Reporting, and Data System (TIRADS) classification. Using the American College of Radiologists TIRADS, the upper pole location also demonstrated a slightly significant association with malignancy (OR, 6.92; 95% CI, 1.02 to 46.90; P=0.047).

Conclusion

The risk of thyroid malignancy was found to be significantly higher for mid-lobar nodules. This observation was confirmed when suspicious ultrasonographic features were included in a multivariate model, suggesting that the longitudinal location in the lobe may be a risk factor independently of ultrasonographic appearance.

IS IT WORTH SUPPRESSING TSH IN LOW- AND INTERMEDIATE-RISK PAPILLARY THYROID CANCER PATIENTS BEFORE THE FIRST DISEASE ASSESSMENT?

OBJECTIVE

Guidelines recommend thyroid-stimulating hormone (TSH) suppression before the first response to treatment assessment in papillary thyroid cancer (PTC) patients. The aim of this study was to assess the rate of structural disease (SD) in low- and intermediate-risk PTC patients according to TSH levels measured 1 year after primary treatment.

METHODS

A consecutive, prospective series of low- and intermediate-risk PTC patients with 3-years follow-up was collected. TSH, thyroglobulin (Tg), antithyroglobulin antibodies (TgAb), and neck ultrasonography (US) 1 and 3 years after primary treatment were analyzed. Recurrence risk and disease status at 1 year were defined according to the American Thyroid Association (ATA) guidelines and as the presence or absence of SD after 3 years. Patients were grouped according to TSH level at 1 year: group 1, TSH <0.1 μUI/mL; group 2, TSH 0.1 to 0.5 μUI/mL; group 3, 0.5 to 2 μUI/mL; and group 4 >2 μUI/mL.

RESULTS

This study included 263 patients (70.9% female, median age 47.2 years) of whom the risk of recurrence was low in 170 (65%), intermediate-low in 63 (24%), and intermediate-high in 30 (11%). The response to initial treatment at 1 year was excellent in 149 (57%), biochemical incomplete in 18 (7%), indeterminate in 84 (32%), and structural incomplete in 12 (4%). Group 1 consisted of 53 (20%) patients, group 2 of 85 (32%), group 3 of 61 (23%), and group 4 of 64 (24%). The rate of SD at 1 and 3 years from primary treatment was not significantly different between TSH groups.

CONCLUSION

TSH suppression before the first response to treatment assessment does not appear to influence the rate of SD evaluated 1 and 3 years after primary treatment.

ABBREVIATIONS

ATA = American Thyroid Association; DTC = differentiated thyroid cancer; FTC = follicular thyroid cancer; LT4 = levothyroxine; PTC = papillary thyroid cancer; SD = structural disease; Tg = thyroglobulin; TgAb = antithyroglobulin antibodies; TSH = thyroid-stimulating hormone; US = ultrasonography.

Design of gamma-ray spectrometers optimized for fast particle studies at ITER

A set of gamma ray spectrometers has been designed for ITER within the Radial Gamma Ray Spectrometer (RGRS) project. The aim of this project is designing a system, integrated with the ITER radial neutron camera, which is able to measure the gamma-rays emitted from the plasma with a good energy resolution (about 1.5% at 4.44 MeV) and at high counting rates (in excess of 1 MHz). The RGRS will be able to operate both in the D phase and in the full-power DT phase and will measure gamma rays from (i) reactions between fast ions, such as α particles, and light impurities and (ii) bremsstrahlung emission generated by runaway electron interactions with both plasma bulk and tokamak walls. The RGRS detectors are arranged in nine lines of sights (able to cover a radial region with r < a/3), each featuring a large LaBr₃ scintillator crystal. Due to the high neutron flux and magnetic field, several solutions have been adopted to guarantee a good signal to background ratio and MHz counting rate capabilities. The RGRS is capable to combine space and energy distribution measurements of α particles and runaway electrons, which will help the study of the fast particle physics in a burning plasma.

Development of a new compact gamma-ray spectrometer optimised for runaway electron measurements

A new compact gamma-ray spectrometer was developed in order to optimise the measurement of bremsstrahlung radiation emitted from runaway electrons in the MeV range. The detector is based on a cerium doped lutetium-yttrium oxyorthosilicate (LYSO:Ce) scintillator coupled to a silicon photomultiplier and is insensitive to magnetic fields. A dedicated electronic board was developed to optimise the signal readout as well as for online control of the device. The detector combines a dynamic range up to 10 MeV with moderate energy non-linearity, counting rate capabilities in excess of 1 MHz, and an energy resolution that extrapolates to a few % in the MeV range, thus meeting the requirements for its application to runaway electron studies by bremsstrahlung measurements in the gamma-ray energy range.

Neutron emission spectroscopy of D plasmas at JET with a compact liquid scintillating neutron spectrometer

Neutron emission spectroscopy is a diagnostic technique that allows for energy measurements of neutrons born in nuclear reactions. The JET tokamak fusion experiment (Culham, UK) has a special role in this respect as advanced spectrometers for 2.5 MeV and 14 MeV neutrons have been developed here for the first time for measurements of the neutron emission spectrum from D and DT plasmas with unprecedented accuracy. Twin liquid scintillating neutron spectrometers were built and calibrated at the Physikalisch-Technische Bundesanstalt (PTB) (Braunschweig, Germany) and installed on JET in the recent years with tangential-equatorial (KM12) and vertical-radial (KM13) view lines, with the latter only recently operational. This article reports on the performance of KM12 and on the development of the data analysis methods in order to extract physics information upon D ions kinematics in JET auxiliary-heated D plasmas from 2.5 MeV neutron measurements. The comparison of these results with the correspondents from other JET neutron spectrometers is also presented: their agreement allows for JET unique capability of multi-lines of sight neutron spectroscopy and for benchmarking other 14 MeV neutron spectrometers installed on the same lines of sight in preparation for the DT experimental campaign at JET.

High resolution gamma-ray spectrometer with MHz capabilities for runaway electron studies at ASDEX Upgrade

A new gamma-ray spectrometer with MHz capabilities has been developed to measure the bremsstrahlung emission spectrum in the gamma-ray energy band generated by MeV range runaway electrons in disruption experiments at ASDEX Upgrade. Properties of the runaway electrons are inferred from the measured bremsstrahlung spectrum by a deconvolution technique, particularly with regard to their maximum energy. Changes induced to the runaway electron velocity space are unambiguously observed both in massive gas injection and resonant magnetic perturbation experiments with the detector.