Prognostic value of prior malignancy history in stage I differentiated thyroid cancer: a SEER-based study

Background

Thyroid cancer is the most common endocrine cancer today. Differentiated thyroid cancer (DTC) comprises more than 95% of all thyroid cancers. With the increasing incidence of tumors and development of screening, more patients suffer from multiple cancers. The purpose of this study was to explore the prognostic value of a history of prior malignancy for stage I DTC.

Methods

Stage I DTC patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The Kaplan-Meier method and Cox proportional hazards regression method were used to determine the risk factors for overall survival (OS) and disease-specific survival (DSS). A competing risk model was also used to determine the risk factors for DTC-related death after considering the competitive risks. In addition, conditional survival analysis in patients with stage I DTC was performed.

Results

A total of 49,723 patients with stage I DTC were enrolled in the study, and 4,982 (10.0%) had prior malignancy history. Prior malignancy history was a factor affecting OS (P<0.001) and DSS (P<0.001) in the Kaplan-Meier analysis and an independent risk factor for OS [hazard ratio (HR) =3.6, 95% confidence interval (CI): 3.17-4.088, P<0.001] and DSS (HR =4.521, 95% CI: 2.224-9.192, P<0.001) in the multivariate Cox proportional hazards regression analysis. In the competing risk model, in the multivariate analysis, prior malignancy history was a risk factor for the DTC-related deaths [subdistribution HR (SHR) =4.32, 95% CI: 2.233-8.3593, P<0.001] after considering the competitive risks. Conditional survival showed that the probability of achieving 5-year DSS was not changed in either the two groups with or without prior malignancy history. For the patients with prior malignancy history, the probability of achieving 5-year OS increased with each additional year survived, but for the patients without prior malignancy history, the improvement of conditional OS only appeared with 2 years already prior survived.

Conclusions

Prior malignancy history has an adverse impact on the survival of patients with stage I DTC. The probability of achieving 5-year OS for stage I DTC patients with prior malignancy history increases with each additional year survived. The inconsistent survival effects of prior malignancy history should be considered in clinical trial design and recruitment.

Papillary thyroid carcinoma with rare lymph node metastasis between the non-ipsilateral sternocleidomastoid and striate muscles: two case reports and literature review

Background

Differentiated thyroid cancer (DTC) has a high incidence but a generally good prognosis. However, lymph node metastasis is likely to occur. It usually metastasizes from the central group lymph nodes to the deep cervical lymph nodes and less frequently to the sternocleidomastoid-sternohyoid muscle. The lymph nodes between the sternocleidomastoid and sternohyoid muscles (LNSS) is easily overlook. Ignoring the preoperative assessment and dissection of level LNSS, especially in the contralateral neck level LNSS, may lead to incomplete surgery and thus require reoperation. The metastatic relevant factors and pathway for LNSS remains inconclusive require further investigation. There is a lack of reports of contralateral or bilateral cervical level LNSS metastasis in thyroid cancer. We hope to arouse attention to the level LNSS through our two case reports.

Case Description

We report two cases of non-ipsilateral LNSS metastases. The patients were diagnosed with thyroid cancer by fine-needle aspiration (FNA), and ultrasound examination showed enlarged lymph nodes at the LNSS level. After surgical treatment and postoperative paraffin pathology, both patients were diagnosed with papillary thyroid carcinoma (PTC) and LNSS-level lymph node metastasis. Case 1 was a 63-year-old woman admitted to our hospital with a 15-day history of an untreated thyroid nodule and preoperative euthyroidism. This patient underwent total thyroidectomy, central and left neck LNSS dissection. Her prognosis was good, and there were no signs of recurrence at her 6-month follow-up appointment; Case 2 was a 24-year-old woman admitted to our hospital for a physical examination of an anterior cervical mass that had been present for 1 year and preoperative euthyroidism. This patient underwent total thyroidectomy, central and bilateral neck LNSS dissection. Her prognosis was good, and there were no signs of recurrence at her 12-month follow-up appointment.

Conclusions

The occurrence of contralateral and bilateral simultaneous LNSS metastasis in thyroid cancer is relatively rare. However, in clinical practice, surgeons should focus on the evaluation and clearance of LNSS, especially in patients with cancer foci located in the lower pole, cancer foci invading the anterior cervical band muscle, extensive metastasis in the lateral cervical lymph nodes or stages T3/4 and to reduce postoperative recurrence.

Assessing potential impact of 2015 American Thyroid Association guidelines on community standard practice for I-131 treatment of low-risk differentiated thyroid cancer: case study of Jordan

OBJECTIVES

The 2015 American Thyroid Association (ATA) guidelines called for significantly more selective ¹³¹I therapy in patients with low-risk differentiated thyroid cancer (DTC). We hypothesized that application of these guidelines would significantly reduce the ¹³¹I activity utilized by an academic tertiary hospital in Jordan.

METHODS

All DTC patients managed at Jordan University Hospital (JUH) between 1/2009 and 6/2019 were classified according to the 2015 ATA risk category and ¹³¹I activity was assigned accordingly. The actual ¹³¹I activity administered was compared with that recommended by the 2015 ATA guidelines.

RESULTS

In total, 135/182 DTC patients (74.2%) managed at JUH underwent ¹³¹I therapy. Of those, 58 (43%) had ATA low-, 58 (43%) intermediate-, and 19 (14%) high-risk disease. The low-, intermediate-, and high-risk DTC patients received an average (±SD) initial ¹³¹I activity of 3.53 ± 0.95, 4.40 ± 1.49, and 5.06 ± 2.52 GBq, respectively. Withholding ¹³¹I therapy altogether in the 2015 ATA low-risk patients would result in decreasing the ¹³¹I activity in the overall patient population by 37%. Withholding ¹³¹I therapy only in low-risk papillary thyroid microcarcinomas while administering 1.11 GBq of ¹³¹I to other low-risk patients would result in 28% reduction of ¹³¹I.

CONCLUSION

This study demonstrates a significant reduction in ¹³¹I therapeutic activity that would be given to DTC patients in an academic tertiary setting in Jordan, following acceptance of the 2015 ATA recommendations. Institutions that adopted the 2015 ATA guidance should measure outcomes in comparison to their historical controls and report those findings, while long-term results of randomized controlled trials are forthcoming.

Identification and validation of potential novel biomarkers to predict distant metastasis in differentiated thyroid cancer

Background

Distant metastasis (DM) is not common in differentiated thyroid cancer (DTC). However, it is associated with a significantly poor prognosis. Early detection of high-risk DTC patients is difficult, and the molecular mechanism is still unclear. Therefore, the present study aims to establish a novel predictive model based on clinicopathological parameters and DM-related gene signatures to provide guidelines for clinicians in decision making.

Methods

Weighted gene co-expression network analysis (WGCNA) was performed to discover co-expressed gene modules and hub genes associated with DM. Univariate and multivariate analyses were carried out to identify independent clinicopathological risk factors based on The Cancer Genome Atlas (TCGA) database. An integrated nomogram prediction model was established. Finally, real hub genes were validated using the GSE60542 database and various thyroid cell lines.

Results

The midnightblue module was most significantly positively correlated with DM (R=0.56, P=9e-06) by as per WGCNA. DLX5 (AUC: 0.769), COX6B2 (AUC: 0.764), and LYPD1 (AUC: 0.760) were determined to be the real hub genes that play a crucial role in predicting DM. Meanwhile, univariate and multivariate analyses demonstrated that T-stage (OR, 15.03; 95% CI, 1.75-319.40; and P=0.024), histologic subtype (OR, 0.17; 95% CI, 0.03-0.92; and P=0.042) were the independent predictors of DM. Subsequently, a nomogram model was constructed based on gene signatures and independent clinical risk factors exhibited good performance. Additionally, the mRNA expressions of real hub genes in the GSE60542 dataset were consistent with TCGA.

Conclusions

The present study has provided a reliable model to predict DM in patients with DTC. This model is likely to serve as an individual risk assessment tool in therapeutic decision-making.

Significance of "de novo" appearance of thyroglobulin antibodies in patients with differentiated thyroid cancer

OBJECTIVE

Clinical and laboratory guidelines recommend thyroglobulin antibodies (TgAbs) measurement with every thyroglobulin (Tg) measurement for the follow-up of differentiated thyroid cancer (DTC) patients. However, no evidence exists on the need for perpetual TgAbs testing in patients who are TgAb-negative at baseline. Our study was carried out to evaluate the prevalence, the dynamic changes, and the clinical significance of TgAbs that appeared de novo during the follow-up of DTC patients who were TgAb-negative at baseline.

METHODS

The data of DTC patients with negative pre-ablation TgAbs were reviewed retrospectively. The main characteristics of patients with both transient and sustained de novo TgAbs appearance were analyzed. DTC patients with persistently negative TgAbs served as controls.

RESULTS

Among 119 patients with pre-ablation negative TgAbs, 14 cases (11.7%) with de novo TgAbs appearance (10 and 4 patients with a transient and sustained de novo TgAbs appearance, respectively) were detected. No differences in disease-free survival were observed in patients with de novo TgAbs appearance compared to controls. The TgAbs peak value was higher in patients with sustained de novo appearance compared to patients with transient de novo. Two of 14 patients with de novo TgAbs developed structural disease with concurrently detectable Tg in both cases.

CONCLUSIONS

Transient de novo TgAbs appearance is not infrequent during DTC patients' follow-up, and it has no apparent clinical impact. Sustained de novo TgAbs appearance is rare and may predict structural recurrences; however, similar disease-free survival was observed in patients with sustained de novo TgAbs and TgAb-negative DTC patients.

Low-dose radioiodine therapy for patients with intermediate- to high-risk differentiated thyroid cancer

OBJECTIVE

The efficacy of low-dose radioiodine therapy (RIT) for intermediate-risk or high-risk differentiated thyroid cancer (DTC) patients is controversial. Because of the country's shortage of medical facilities for RIT, 1110-MBq RIT for higher risk DTC patients has been performed on an outpatient basis since 2010 in Japan. Herein, we addressed this issue and attempted to determine prognostic factors for the prediction of RIT outcomes.

METHODS

We retrospectively analyzed the cases of 119 patients with papillary thyroid cancer who underwent their first RIT with 1110 MBq radioactive iodine (RAI) following a total thyroidectomy, including 65 (54.6%) intermediate-risk and 54 (45.4%) high-risk patients (according to Japan's 2018 clinical practical guidelines for thyroid tumors). Successful ablation was defined when a negative I-131 whole-body scan and thyroglobulin (Tg) < 2 ng/mL were obtained at a diagnostic scan performed 148-560 days (median 261 days) after the first RIT.

RESULTS

The overall ablation success rate was 23.4%. Although the ablation success rates of each pretreatment protocol [recombinant human thyroid stimulating hormone and thyroid hormone withdrawal (THW)] did not differ significantly, THW tended to result in a higher success rate than rhTSH. The Tg level at RIT was the only independent powerful predictive factor for successful ablation. The best cut-off value of Tg for predicting unsuccessful ablation was 9 ng/mL.

CONCLUSIONS

The ablation success rate was much lower than those of earlier studies; the most plausible reason would be that higher risk DTC patients were included in this study. The low-dose RIT routinely performed in Japan might be inadequate for the achievement of successful ablation. At least for patients with Tg > 9 ng/mL at the first RIT, a higher dose of RAI is recommended.

Pre-operative serum TSH levels: A risk factor for advanced metastatic differentiated thyroid carcinoma

Background and Objective:

As the thyroid cancer incidence is increasing, the search for its risk factor is becoming more important. Serum thyroid stimulating hormone (TSH) levels being a growth factor for normal thyroid tissue, is also considered as growth promotor of cancer cells. In our study we aimed for pre-operative serum TSH levels of Differentiated thyroid cancers (DTC) done before their first surgery and determined its association with advanced disease in terms of stage, multifocal disease, lymph node involvement and distant metastasis.

Methods:

We have conducted a retrospective review of thyroid cancers from 1^st January 2008 to 31^st December 2017. Out of 281, 142 cases were included according to inclusion criteria. We noted the demographic details of participants, their histopathological diagnosis and serum TSH levels done before first surgery from the medical records. We calculated the stage of tumor through modified American Joint Committee (AJCC) staging system.

Results:

Out of 147 participants, 89.4% had papillary carcinoma or its variants whereas 10.6% reported follicular carcinoma. The mean pre-op TSH level of the patients included was 2.04 ± 1.79. In addition to the descriptive analysis, the univariate regression analysis revealed that the association of serum TSH levels was found to be statistically insignificant with advanced stage of thyroid cancer, multifocal disease, lymph node metastasis and distant metastasis respectively.

Conclusion:

The serum TSH levels before surgery was not associated with poor prognosis of differentiated thyroid cancer with respect to higher staging, multifocal disease, lymphatic or distant metastasis.

Completion Thyroidectomy in Differentiated Thyroid Malignancy-A Prospective Analysis

Completion thyroidectomy, being a surgically challenging procedure, choice of doing such procedure in differentiated thyroid cancer (DTC), remains unclear due to the complications involved following the procedure. So this study is intended to look into risk factors that will prompt completion thyroidectomy and surgery-related complications. A prospective analysis was done in 48 patients diagnosed with DTC during the year 2017. Completion thyroidectomy with or without neck dissection was performed as per institutional protocol. Clinico-radiological features were compared with histopathology in completion thyroidectomy specimen. The incidence of malignancy in completion thyroidectomy specimen and complications during the procedure were noted. Risk factors associated with malignancy were statistically analyzed. The incidence of malignancy in completion thyroidectomy specimen was 56.25%. Papillary carcinoma thyroid (PCT) had a statistically significant risk compared to follicular carcinoma thyroid (p = 0.042). Also, capsular invasion in primary specimen had a significant impact (p = 0.021) with odds of 7.20 times increase in incidence of malignancy and patients with age more than 55 years had a significantly increased risk of malignancy (p = 0.05). There was no statistically significant increase in complications following procedure, with respect to duration between surgeries or type of surgeries performed. Incidence of malignancy in completion thyroidectomy specimen was high. Completion thyroidectomy can be safely performed under experienced hands with an acceptable level of complications. It should be considered in places where patients are non-compliant and in those with PCT, tumor with capsular invasion and elderly patients.

Current controversies and future directions in the diagnosis and management of differentiated thyroid cancers

Despite the development of novel diagnostic, surgical, and chemotherapeutic approaches to differentiated thyroid cancers (DTCs), the diagnosis and management of these tumors remains controversial. The most recent American Thyroid Association (ATA) guidelines, released in 2015, reflect a recent shift towards less aggressive management for patients with DTCs. However, many clinicians have expressed concern that more conservative management will put patients at risk for disease recurrence and metastasis. In particular, the management of indeterminate nodules on fine needle aspiration (with special attention to genetic and epigenetic markers of malignancy), the extent of surgery for known differentiated cancers, the role of adjuvant radioactive iodine (RAI) therapy, and novel targeted treatments with tyrosine kinase inhibitors (TKIs) represent current areas of uncertainty and opportunities for future research. In this review, we examine the current state of the art in these areas, and address some of the questions that remain.

Predictive factors for recurrence of differentiated thyroid cancer in patients under 21 years of age and a meta-analysis of the current literature

The influence of predictors for recurrence in relation to recurrence-free survival was analyzed retrospectively in differentiated thyroid cancer (DTC) patients under 21 years of age who underwent primary surgical treatment and who had a pathological diagnosis of DTC between 1983 and 2012 at Fudan University Cancer Hospital. Recurrences were retrospectively analyzed using a Cox regression model for the hazard ratio (HR) according to the clinicopathological features. A meta-analysis was performed with respect to the potential predictors for recurrence from current related studies. In the present study, there were 146 young patients aged from 7 to 20 years, with a female/male ratio of 2.65/1. Female gender was the only factor significantly associated with recurrence according to univariate (HR = 2.812, P = 0.037) and multivariate (HR = 4.107, P = 0.024) Cox regression analyses. Meta-analyses revealed that multifocality (HR = 1.91, P < 0.05) and presentation at diagnosis (HR = 1.39, P < 0.05) were highly associated with recurrence in young DTC patients. However, female gender and other factors, such as age (≤10 vs. 11-20 years), PTC (PTC vs. FTC), extrathyroidal extension, lymph node metastasis, total thyroidectomy (total vs. less than total), radioiodine therapy, and radiation history, were not associated with recurrence in young DTC patients. In conclusion, multifocality and presentation at diagnosis are strong predictive factors of recurrence in relation to recurrence-free survival. We recommend studies with larger sample sizes and longer follow-up to verify the influence of predictors for disease recurrence in young patients.

Evaluation of serum midkine as a biomarker in differentiated thyroid cancer

AIMS

Midkine is a multifunctional cytokine identified to be a promising cancer biomarker. We aimed to prospectively investigate serum midkine as a diagnostic and prognostic biomarker in differentiated thyroid cancer (DTC).

MAIN METHODS

162 patients with thyroid nodules participated in the surgical cohort (post-surgical pathology proved 70 cases with DTC and 92 cases with benign thyroid nodules), 75 healthy subjects served as control. Diagnostic values of pre-surgical midkine and thyroglobulin for DTC were conducted by receiver operating characteristic (ROC) curves. 214 DTC patients participated in the (131)I treatment cohort. Prognostic values of pre-(131)I-ablative midkine and thyroglobulin to predict (131)I-avid metastases were performed by ROC curves. Metastasis-free survival was analyzed by the Kaplan-Meier method.

KEY FINDINGS

Much better diagnostic capability of midkine than thyroglobulin was shown to differentiate DTC from benign thyroid nodules, with cut-off midkine value of 323.12pg/ml and diagnostic accuracy of 75.31%. Nearly similar diagnostic capabilities of midkine and thyroglobulin were shown to distinguish DTC from normal participants. Pre-(131)I-ablative thyroglobulin demonstrated perfect ability to predict metastases, with cut-off value and diagnostic accuracy of 19.50ng/ml and 96.73%. Midkine also performed well with a cut-off value and diagnostic accuracy of 504.71pg/ml and 89.25%. DTC patients with midkine or thyroglobulin levels higher than those of thresholds (500pg/ml or 20ng/ml) showed a significantly worse (131)I-avid metastasis-free survival by the Kaplan-Meier method (P<0.01).

SIGNIFICANCE

Our results show that midkine is as good as or even better than thyroglobulin to screen patients with thyroid nodules for DTC before surgery, and to predict whether metastases exist before the first (131)I ablative therapy.

The effect of neck dissection on quality of life in patients with differentiated thyroid cancer

Cervical lymph node metastases are very common in patients with differentiated thyroid cancer (DTC). The overall long term survival rate in patients with DTC is higher than 90%, with variations in subsets of groups. Despite that DTC has an excellent prognosis, lymphatic spread is associated with increased risk of loco-regional recurrence, which significantly impairs quality-of-life (QOL) and can alter prognosis of the patient. As a result, a rapid shift in patient care from a focus on overall survival to a focus on recurrence-free survival has recently noted. The appropriate lymph node dissection is of great importance in order to achieve this goal. This surgical strategy will prevent disease recurrence, which may require an additional and more morbid surgery. Traditionally, the main outcome measure in oncology patients has been survival, based on tumor control, but recently it has been increasingly recognized that the diagnosis and management of cancer can have a major effect on every aspect of the QOL of a patient. The aims of cancer treatment became not only to increase survival but also to preserve QOL, and measuring these changes has been considered to be of paramount importance.

MRI and ultrasonography detection of cervical lymph node metastases in differentiated thyroid carcinoma before reoperation

OBJECTIVE

The purpose of this study was to compare the diagnostic capabilities of magnetic resonance imaging (MRI) and ultrasonography (US) for cervical lymph nodal metastases in differentiated thyroid carcinoma (DTC) before reoperation.

MATERIAL AND METHOD

From June 2011 to May 2013, preoperative MRI and ultrasound data were collected from differentiated thyroid cancer patients who underwent a reoperation. The following characteristics were assessed: the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of MRI and US. The MRI and ultrasound findings were correlated with the histological diagnosis after reoperation.

RESULTS

One hundred and thirty-eight cases were included in the analysis. 88.4% (122/138) of which had evidence of residual thyroid cancer tissue or metastatic nodal involvement at final histology. Lymph nodal metastases were confirmed in the central compartment in 76.42% (81/106) of patients and in lateral compartment in 73.28% (85/116) of patients. The sensitivity, specificity and accuracy of MRI VS US for detecting central compartment metastases was 75% VS 41.67% (P=0.04), 90.91% VS 100% (P=1) and 80% VS 60% (P=0.618), respectively; For detecting lateral compartment metastases was 83.33% VS 77.78% (P=1), 25% VS 50% (P=0.606) and 65.38% VS 69.23% (P=1), respectively. There was statistically significant difference between the sensitivity of MRI and ultrasound for diagnose of central compartment metastases. The MRI features with the greatest correlation with positive lymph nodal metastases were fusion and enhancing lesions. The ultrasound features with the greatest correlation with positive lymph nodal metastases were hypoechoic and microcalcifications.

CONCLUSION

MRI is more sensitive than ultrasonography in detecting central compartment metastases in papillary thyroid carcinoma. There is no significant difference in diagnosis of lateral neck node metastases between MRI and US.