Physicians' preferencesfor radioiodine treatment of differentiated thyroid cancer in Brazil: an observational study.

Objective: The aim of this observational, cross-sectional study was to investigate physicians' preferences for radioiodine (RAI) treatment in patients with differentiated thyroid cancer (DTC) in Brazil and the factors influencing RAI indications. Materials and methods: A survey was distributed to physicians potentially involved in DTC care in Brazil to understand the factors influencing RAI indications. The survey collected information on the profiles of the physicians, along with the characteristics of their workplaces and their preferences regarding RAI indications in three hypothetical clinical cases. Cases 1, 2, and 3 described the cases of patients with DTC and variations to the case that included different scenarios to assess how the respondents would change their RAI recommendations. The analysis included the RAI indications across different medical specialties. Results: A total of 175 physicians answered the survey. There was considerable variability in RAI recommendations in all three cases. The training background influenced the respondents' preferences for RAI indications and their approaches to preparing patients for RAI treatment. Conclusion: The findings of this study reaffirm the need for a Brazilian consensus among physicians across multiple specialties to help guide health care professionals treating patients with DTC in Brazil.

TERT mutations and aggressive histopathologic characteristics of radioiodine-refractory papillary thyroid cancer.

Background: Radioiodine (RI) ablation following thyroid-stimulating hormone suppression is an effective treatment for papillary thyroid cancer (PTC), typically leading to favorable outcomes. However, RI-refractory tumors exhibit aggressive behavior and poor prognoses. Recent studies highlight the role of genetic abnormalities in PTC signaling pathways, including the activation of telomerase reverse transcriptase (TERT), and the correlation of mutations with adverse outcomes. Methods: This study analyzed mutations in BRAF V600E and the TERT-promoter genes, comparing clinicopathological features between RI-refractory and RI-responsive PTCs. Among 82 RI-refractory patients, formalin-fixed, paraffin-embedded tissues from initial surgeries were available for 26. Another 89 without distant metastasis over 5 years formed a matched RI-responsive control group. Results: Histopathologically, RI-refractory PTCs showed increased frequencies of small tumor clusters without fibrovascular cores, hobnail features, and a high height-to-width ratio of tumor cells. These tumors were more likely to exhibit necrosis, mitosis, lymph node metastasis, extrathyroidal extension, and involvement of resection margins. TERT-promoter mutations were statistically significantly associated with these aggressive clinicopathologic features. Immunohistochemically, decreased expression of sodium iodide symporter and thyroglobulin stimulating hormone receptor proteins was common in RI-refractory PTCs, along with lower levels of oncogenic proteins such as vascular endothelial cell growth factor, vascular endothelial cell growth factor receptor 2, and nuclear factor kappa-light-chain-enhancer of activated B cells. Total loss of PTEN expression was occasionally observed. In contrast, all cases tested positive for cytoplasmic ß-catenin. Conclusions: RI-refractory PTCs are linked to TERT mutations and exhibit specific aggressive histopathologic features, particularly in tumor centers.

Predictive value of an ultrasound-based radiomics model for central lymph node metastasis of papillary thyroid carcinoma.

Purpose: We aimed to explore the predictive value of an ultrasound-based radiomics model for the central lymph node metastasis of papillary thyroid carcinoma. Methods: A total of 126 patients with papillary thyroid carcinoma treated between February 2021 and February 2023 were retrospectively enrolled and assigned into metastasis group (n=59, with cervical central lymph node metastasis) or non-metastasis group (n=67, without metastasis) based on surgical and pathological findings. Intergroup comparisons were conducted on the results of contrast-enhanced ultrasonography, preoperative conventional ultrasonography, as well as real-time shear wave elastography. Results: The maximum lesion diameter, echo, margin, capsule invasion, calcification, average elasticity modulus (Eavg), rising time (RT), and peak intensity (PI) had diagnostic value for papillary thyroid carcinoma, and their combination exhibited higher diagnostic value (area under the curve: 0.817). The logistic regression model was built, and the maximum lesion diameter, hypoechoic/extremely hypoechoic, lobulated or irregular margin (95% confidence interval: 1.451-6.755), capsule invasion, microcalcification/macrocalcification or peripheral calcification, high-level Eavg, low-level RT and high-level PI served as risk elements affecting papillary thyroid carcinoma from the aspect of central lymph node metastasis (odds ratio>1, P<0.05). According to the logistic regression model, the model was reliable and stable (area under the curve: 0.889, P<0.05). Conclusion: The established ultrasound-based radiomics model can be utilized for early identifying the central lymph node metastasis of papillary thyroid carcinoma.

Immunohistochemistry and next-generation sequencing for NTRK fusion detection in differentiated thyroid cancer of children, adolescents and young adults / Imunohistoquímica e sequenciamento nova geração para detecção de fusão NTRK em câncer diferenciado de tireoide em crianças, adolescentes e adultos jovens

INTRODUCTION: Pan-TRK immunohistochemistry staining can assess the protein expression from NTRK gene fusions. A little is known about its utility in differentiated thyroid cancer samples from children, adolescents, and young adults patients. Objective: Investigate pan-TRK immunohistochemistry sensitivity and specificity in differentiated thyroid cancer samples from children, adolescents, and young adults patients. METHODS: Tumor samples obtained from 79 children, adolescents, and young adults patients (age <21 years) diagnosed with differentiated thyroid cancer between January, 2010 and January, 2021 were retrospectively recruited from four health centers from state of Bahia e Paraíba, Brazil. NTRK gene fusion testing of all archival FFPE tumor samples: pan-TRK immunohistochemistry staining for TRKA, TRKB and TRKC protein expression were performed and then analyzed with RNA-based next-generation sequencing assay to confiC:\Users\yngrid.narciso\Desktop\CLIENTES\SITES\BJO\2024\5 - Maio\2024-05-02\siterm immunohistochemistry pan-TRK result and elucidate fusion partner. RESULTS: Pan-TRK immunohistochemistry: 3 of 79 cases had positive pan-TRK expression: next-generation sequencing; 4 were identified with NTRK gene fusion, pan-TRK immunohistochemistry was negative in all 4 NTRK next-generation sequencing-positive cases. 25 of 79 NTRK next-generation sequencing-negative control cases had concordant negative pan-TRK immunohistochemistry results. Therefore, our rate of false positive pan-TRK immunohistochemistry results was 3/25 (12%). The overall results for pan-TRK immunohistochemistry in our cohort of next-generation sequencing-negative cases was: (i) sensitivity (0%), (ii) specificity (96%), (iii) positive predictive value (94.7%), (iv) negative predictive value (91%). CONCLUSION: Pan-TRK immunohistochemistry was not a tissue-efficient screen for NTRK fusions in differentiated thyroid cancer from children, adolescents, and young adults patients. This is the largest cohort of from children, adolescents, and young adults differentiated thyroid cancer cases stained with pan-TRK immunohistochemistry, and it is the first to detail the sensitivity and specificity of pan-TRK immunohistochemistry regarding the data obtained by targeted RNA-based next-generation sequencing panel in differentiated thyroid cancer.

INTRODUÇÃO: A coloração imuno-histoquímica Pan-TRK pode avaliar a expressão proteica de fusões de genes NTRK. Pouco se sabe sobre sua utilidade em amostras diferenciadas de câncer de tireoide de crianças, adolescentes e adultos jovens. Objetivo: Investigar a sensibilidade e especificidade da imuno-histoquímica pan-TRK em amostras diferenciadas de câncer de tireoide de pacientes crianças, adolescentes e adultos jovens. MÉTODOS: Amostras tumorais obtidas de 79 pacientes crianças, adolescentes e adultos jovens (idade <21 anos) com diagnóstico de câncer diferenciado de tireoide entre janeiro de 2010 e janeiro de 2021 foram recrutadas, retrospectivamente, em quatro centros de saúde dos estados da Bahia e Paraíba, Brasil. Teste de fusão genética NTRK de todas as amostras de tumor FFPE arquivadas: coloração imuno-histoquímica pan-TRK para expressão da proteína TRKA, TRKB e TRKC foi realizada e depois analisada com ensaio de sequenciamento de próxima geração baseado em RNA, para confirmar o resultado imuno-histoquímico pan-TRK e elucidar o parceiro de fusão. RESULTADOS: Imunohistoquímica pan-TRK: 3 de 79 casos tiveram expressão pan-TRK positiva: sequenciamento de próxima geração; 4 foram identificados com fusão do gene NTRK, a imuno-histoquímica pan-TRK foi negativa em todos os 4 casos positivos para sequenciamento de próxima geração de NTRK. 25 dos 79 casos de controle negativo para sequenciamento de próxima geração de NTRK tiveram resultados de imuno-histoquímica pan-TRK negativos concordantes. Portanto, nossa taxa de resultados de imuno-histoquímica pan-TRK falsos positivos foi de 3/25 (12%). Os resultados gerais da imuno-histoquímica pan-TRK em nossa coorte de casos negativos para sequenciamento de próxima geração foram: (i) sensibilidade (0%), (ii) especificidade (96%), (iii) valor preditivo positivo (94,7%), (iv) valor preditivo negativo (91%). CONCLUSÃO: A imuno-histoquímica pan-TRK não foi uma triagem tecidualmente eficiente para fusões de NTRK em pacientes com câncer diferenciado de tireoide em crianças, adolescentes e adultos jovens. Esta é a maior coorte de casos de câncer diferenciado de tireoide de crianças, adolescentes e adultos jovens corados com imunohistoquímica pan-TRK, e é a primeira a detalhar a sensibilidade e especificidade da imunohistoquímica pan-TRK em relação aos dados obtidos por RNA direcionado baseado em um painel de sequenciamento de próxima geração no câncer diferenciado de tireoide.

Utilizing Immunoglobulin G4 Immunohistochemistry for Risk Stratification in Patients with Papillary Thyroid Carcinoma Associated with Hashimoto Thyroiditis.

BACKGRUOUND: Hashimoto thyroiditis (HT) is suspected to correlate with papillary thyroid carcinoma (PTC) development. While some HT cases exhibit histologic features of immunoglobulin G4 (IgG4)-related disease, the relationship of HT with PTC progression remains unestablished. METHODS: This cross-sectional study included 426 adult patients with PTC (≥1 cm) undergoing thyroidectomy at an academic thyroid center. HT was identified based on its typical histologic features. IgG4 and IgG immunohistochemistry were performed. Wholeslide images of immunostained slides were digitalized. Positive plasma cells per 2 mm2 were counted using QuPath and a pre-trained deep learning model. The primary outcome was tumor structural recurrence post-surgery. RESULTS: Among the 426 PTC patients, 79 were diagnosed with HT. With a 40% IgG4 positive/IgG plasma cell ratio as the threshold for diagnosing IgG4-related disease, a cutoff value of >150 IgG4 positive plasma cells per 2 mm2 was established. According to this criterion, 53% (43/79) of HT patients were classified as IgG4-related. The IgG4-related HT subgroup presented a more advanced cancer stage than the IgG4-non-related HT group (P=0.038). The median observation period was 109 months (range, 6 to 142). Initial assessment revealed 43 recurrence cases. Recurrence-free survival periods showed significant (P=0.023) differences, with patients with IgG4 non-related HT showing the longest period, followed by patients without HT and those with IgG4-related HT. CONCLUSION: This study effectively stratified recurrence risk in PTC patients based on HT status and IgG4-related subtypes. These findings may contribute to better-informed treatment decisions and patient care strategies.

Thyroid Incidentalomas: Scrutinizing the Mode of Detection and Evaluating its Contribution to Thyroid Cancer Diagnosis.

There is an ongoing debate about the reasons behind the increasing incidence of thyroid cancer in the last two to three decades. Here, we investigate how thyroid nodules were detected in a large series of consultations for thyroid nodular pathology. METHODS: In total, 576 patients were analyzed, with a total of 1014 nodules described. RESULTS: In 347 (60.2%) cases, the diagnosis of a thyroid nodule was incidental, mostly during imaging tests for other reasons. Incidental diagnosis occurred among all ranges of nodule diameter and between palpable and non-palpable cases, even within a small proportion of symptomatic cases. In univariate analysis, incidental diagnosis was associated with smaller nodule diameter, non-palpable nodules, asymptomatic cases, older patient age, less advanced stages (T1-2), and conservative management. After multivariate analysis, older age, euthyroidism, and smaller diameter were statistically significant. Incidental diagnosis contributed to the diagnosis of 53.8% of the cases of cancer. Advanced T stages (T3-4) were more common in non-incidental diagnoses. CONCLUSION: Our results indicate that incidental diagnosis of thyroid nodules is a significant contributor to thyroid cancer diagnosis in all ranges of nodule diameter, especially at earlier stages.

Clinicopathological Features and Molecular Signatures of Lateral Neck Lymph Node Metastasis in Papillary Thyroid Microcarcinoma.

BACKGRUOUND: The predictive factors for lateral neck lymph node metastasis (LLNM) in papillary thyroid microcarcinoma (PTMC) remain undetermined. This study investigated the clinicopathological characteristics, transcriptomes, and tumor microenvironment in PTMC according to the LLNM status. We aimed to identify the biomarkers associated with LLNM development. METHODS: We retrospectively reviewed the medical records of patients with PTMC from two independent institutions between 2018 and 2022 (n=597 and n=467). We compared clinicopathological features between patients without lymph node metastasis (N0) and those with LLNM (N1b). Additionally, laser capture microdissection and RNA sequencing were performed on primary tumors from both groups, including metastatic lymph nodes from the N1b group (n=30; 20 primary tumors and 10 paired LLNMs). We corroborated the findings using RNA sequencing data from 16 BRAF-like PTMCs from The Cancer Genome Atlas. Transcriptomic analyses were validated by immunohistochemical staining. RESULTS: Clinicopathological characteristics, such as male sex, multifocality, extrathyroidal extension, lymphatic invasion, and central node metastasis showed associations with LLNM in PTMCs. Transcriptomic profiles between the N0 and N1b PTMC groups were similar. However, tumor microenvironment deconvolution from RNA sequencing and immunohistochemistry revealed an increased abundance of tumor-associated macrophages, particularly M2 macrophages, in the N1b group. CONCLUSION: Patients with PTMC who have a male sex, multifocality, extrathyroidal extension, lymphatic invasion, and central node metastasis exhibited an elevated risk for LLNM. Furthermore, infiltration of M2 macrophages in the tumor microenvironment potentially supports tumor progression and LLNM in PTMCs.

Active Surveillance for Low-Risk Papillary Thyroid Carcinoma as an Acceptable Management Option with Additional Benefits: A Comprehensive Systematic Review.

BACKGRUOUND: Active surveillance (AS) has been introduced as a management strategy for low-risk papillary thyroid carcinoma (PTC) due to its typically indolent nature. Despite this, the widespread adoption of AS has encountered several challenges. The aim of this systematic review was to evaluate the safety of AS related to disease progression and its benefits compared with immediate surgery (IS). METHODS: Studies related to AS in patients with low-risk PTC were searched through the Ovid MEDLINE, Embase, Cochrane Library, and KoreaMed databases. Studies on disease progression, surgical complication, quality of life (QoL), and cost-effectiveness were separately analyzed and narratively synthesized. RESULTS: In the evaluation of disease progression, the proportions of cases with tumor growth ≥3 mm and a volume increase >50% were 2.2%-10.8% and 16.0%-25.5%, respectively. Newly detected lymph node metastasis was identified in 0.0%-1.4% of patients. No significant difference was found between IS and delayed surgery in surgical complications, including vocal cord paralysis and postoperative hypoparathyroidism. AS was associated with better QoL than IS. Studies on the cost-effectiveness of AS reported inconsistent data, but AS was more cost-effective when quality-adjusted life years were considered. CONCLUSION: AS is an acceptable management option for patients with low-risk PTC based on the low rate of disease progression and the absence of an increased mortality risk. AS has additional benefits, including improved QoL and greater QoL-based cost-effectiveness.

Retrospective Diagnosis of Ca Thyroid on Thyroid Pertechnetate Scan -A part of Routine Post Thyroidectomy Work up For Nontoxic Multi Nodular Goiter.

Unsuspected thyroid cancer can be detected in multinodular goiter (MNG) where the risk of malignancy is 7-9%. Fine needle aspiration (FNAc) is performed in case of suspicious findings on ultrasound. With benign FNAC results there is no need for surgery unless the patient has pressure symptoms or cosmetic concerns, but the risk of overlooked malignancy is always present. We present the case of a patient with unexpected detection of papillary thyroid cancer on thyroid scan.

Added value of arterial enhancement fraction derived from dual-energy computed tomography for preoperative diagnosis of cervical lymph node metastasis in papillary thyroid cancer: initial results.

OBJECTIVES: To explore the added value of arterial enhancement fraction (AEF) derived from dual-energy computed tomography CT (DECT) to conventional image features for diagnosing cervical lymph node (LN) metastasis in papillary thyroid cancer (PTC). METHODS: A total of 273 cervical LNs (153 non-metastatic and 120 metastatic) were recruited from 92 patients with PTC. Qualitative image features of LNs were assessed. Both single-energy CT (SECT)-derived AEF (AEFS) and DECT-derived AEF (AEFD) were calculated. Correlation between AEFD and AEFS was determined using Pearson's correlation coefficient. Multivariate logistic regression analysis with the forward variable selection method was used to build three models (conventional features, conventional features + AEFS, and conventional features + AEFD). Diagnostic performances were evaluated using receiver operating characteristic (ROC) curve analyses. RESULTS: Abnormal enhancement, calcification, and cystic change were chosen to build model 1 and the model provided moderate diagnostic performance with an area under the ROC curve (AUC) of 0.675. Metastatic LNs demonstrated both significantly higher AEFD (1.14 vs 0.48; p < 0.001) and AEFS (1.08 vs 0.38; p < 0.001) than non-metastatic LNs. AEFD correlated well with AEFS (r = 0.802; p < 0.001), and exhibited comparable performance with AEFS (AUC, 0.867 vs 0.852; p = 0.628). Combining CT image features with AEFS (model 2) and AEFD (model 3) could significantly improve diagnostic performances (AUC, 0.865 vs 0.675; AUC, 0.883 vs 0.675; both p < 0.001). CONCLUSIONS: AEFD correlated well with AEFS, and exhibited comparable performance with AEFS. Integrating qualitative CT image features with both AEFS and AEFD could further improve the ability in diagnosing cervical LN metastasis in PTC. CLINICAL RELEVANCE STATEMENT: Arterial enhancement fraction (AEF) values, especially AEF derived from dual-energy computed tomography, can help to diagnose cervical lymph node metastasis in patients with papillary thyroid cancer, and complement conventional CT image features for improved clinical decision making. KEY POINTS: • Metastatic cervical lymph nodes (LNs) demonstrated significantly higher arterial enhancement fraction (AEF) derived from dual-energy computed tomography (DECT) and single-energy CT (SECT)-derived AEF (AEFS) than non-metastatic LNs in patients with papillary thyroid cancer. • DECT-derived AEF (AEFD) correlated significantly with AEFS, and exhibited comparable performance with AEFS. • Integrating qualitative CT images features with both AEFS and AEFD could further improve the differential ability.

Basal or stimulated thyroglobulin in evaluating response to treatment in papillary thyroid carcinoma? A retrospective cohort study.

OBJECTIVE: It is not clear whether response to initial treatment in papillary thyroid carcinoma (PTC) patients is best evaluated by measuring thyroglobulin (Tg) in the presence of levothyroxine (BTg) or when stimulated by elevated TSH (STg). The aim of this study was to evaluate whether response to therapy 1 year after initial treatment changes with the use of STg in relation to BTg in PTC patients treated with total thyroidectomy (TT) and radioiodine (131I), and, if observed, to assess which response is better associated with clinical course. SUBJECTS AND METHODS: This is a retrospective study of 148 PTC patients submitted to TT and 131I. We analyzed the response to therapy (excellent, biochemical incomplete, or indeterminate) at 1 year after initial treatment, using BTg or STg, and compared which method was better associated with "excellent response at final evaluation." RESULTS: Twenty-eight patients (20.4%) presented change in response to therapy, with 17 of these (60.7%) presenting a worse response. Response using STg was 1.6 times better associated with proposed outcome [odds ratio (OR) = 4.61; confidence interval 95% (IC95%): 2.13-9.98] than with BTg (OR = 2.84; IC95%: 1.33-6.06). CONCLUSION: Response to therapy at 1 year using STg was altered in approximately 20% of cases and therefore proved to be a better predictor of excellent response in the last evaluation.

Physicians' preferences for radioiodine treatment of differentiated thyroid cancer in Brazil: an observational study

ABSTRACT Objective The aim of this observational, cross-sectional study was to investigate physicians' preferences for radioiodine (RAI) treatment in patients with differentiated thyroid cancer (DTC) in Brazil and the factors influencing RAI indications. Materials and methods A survey was distributed to physicians potentially involved in DTC care in Brazil to understand the factors influencing RAI indications. The survey collected information on the profiles of the physicians, along with the characteristics of their workplaces and their preferences regarding RAI indications in three hypothetical clinical cases. Cases 1, 2, and 3 described the cases of patients with DTC and variations to the case that included different scenarios to assess how the respondents would change their RAI recommendations. The analysis included the RAI indications across different medical specialties. Results A total of 175 physicians answered the survey. There was considerable variability in RAI recommendations in all three cases. The training background influenced the respondents' preferences for RAI indications and their approaches to preparing patients for RAI treatment. Conclusion The findings of this study reaffirm the need for a Brazilian consensus among physicians across multiple specialties to help guide health care professionals treating patients with DTC in Brazil.

Comparative Analysis of Driver Mutations and Transcriptomes in Papillary Thyroid Cancer by Region of Residence in South Korea.

BACKGRUOUND: Radiation exposure is a well-known risk factor for papillary thyroid cancer (PTC). South Korea has 24 nuclear reactors in operation; however, no molecular biological analysis has been performed on patients with PTC living near nuclear power plants. METHODS: We retrospectively included patients with PTC (n=512) divided into three groups according to their place of residence at the time of operation: inland areas (n=300), coastal areas far from nuclear power plants (n=134), and nuclear power plant areas (n=78). After propensity score matching (1:1:1) by age, sex, and surgical procedure, the frequency of representative driver mutations and gene expression profiles were compared (n=50 per group). Epithelial-mesenchymal transition (EMT), BRAF, thyroid differentiation, and radiation scores were calculated and compared. RESULTS: No significant difference was observed in clinicopathological characteristics, including radiation exposure history and the frequency of incidentally discovered thyroid cancer, among the three groups. BRAFV600E mutation was most frequently detected in the groups, with no difference among the three groups. Furthermore, gene expression profiles showed no statistically significant difference. EMT and BRAF scores were higher in our cohort than in cohorts from Chernobyl tissue bank and The Cancer Genome Atlas Thyroid Cancer; however, there was no difference according to the place of residence. Radiation scores were highest in the Chernobyl tissue bank but exhibited no difference according to the place of residence. CONCLUSION: Differences in clinicopathological characteristics, frequency of representative driver mutations, and gene expression profiles were not observed according to patients' region of residence in South Korea.

Association of High Serum Leptin Level with Papillary Thyroid Carcinoma: A Case-Control Study.

Background: Recently, the prevalence of thyroid cancer has increased. Although there are known risk factors for thyroid cancer, none of them can justify this recent increase. In addition to the known risk factors, other risk factors have been proposed. Leptin can be considered as one of these risk factors due to the recent increase in the prevalence of obesity in the population. Leptin is a common factor in obesity and thyroid cancer. Leptin exerts anti-apoptotic and mitogenic effects on cancer cells and also acts as an angiogenic factor. This study aimed to evaluate the serum leptin level in individuals who suffer from papillary thyroid carcinoma (PTC), cases with benign thyroid nodules (BTN), and a healthy group. Materials and Methods: In this study, newly diagnosed patients with PTC, BTNs, as well as euthyroid healthy control subjects without nodules were included. In all these participants, various clinical and laboratory parameters including thyroid function tests and serum leptin levels were measured and compared between the three study groups. For patients with PTC, leptin was assessed 12 weeks after total thyroidectomy. Results: Ninety-one cases with PTC, 90 cases with BTNs, and 88 controls were recruited. Serum leptin levels in the PTC group, benign group, and the control group were 22.34, 17.60, and 13.83 ng/ml, respectively, which was considerably higher in PTC cases compared to those with benign nodules and control group (P<0.001). There was a significant association between leptin with BMI, tumor size, and tumor stage in PTC patients. Also, in patients with BTNs, a correlation between BMI, tumor size, and leptin was observed. Conclusion: Serum leptin levels were considerably higher in cases with PTC than those with BTNs and controls and can be considered as a potential tumor marker for papillary thyroid cancer.

A rare incidence of mandibular metastasis of papillary thyroid carcinoma: A case report and review of literature.

Papillary Thyroid Carcinoma (PTC) primarily metastasizes via regional lymphatics making its spread to the oral cavity exceedingly rare. Although this disease remains the most common endocrine malignancy, comprising roughly 85%-90% of all thyroid cancers, its occurrence within the oral cavity happens in less than 1% of oral malignancies. This study identifies a case involving a 77-year-old male with a history of well-differentiated PTC that was initially treated with a total thyroidectomy and adjuvant radioactive iodine. Five years after his initial treatment, surveillance imaging demonstrated a 3 cm expansile mass of the left mandible. An incisional biopsy then confirmed the diagnosis of metastatic PTC. A segmental resection of his mandible was completed with final reconstruction utilizing a fibula free flap. Given the limited number of cases involving metastatic spread of PTC to the oral cavity, a standardized treatment algorithm does not exist. Thus, this case serves to provide a documented report of this rare occurrence and to review literature that may help other clinicians treat patients with this malignancy type. There remains a need for future studies to create risk stratification models for patients with metastatic PTC that consider margin analysis, genetic characteristics, and risk factors to tailor individual treatment plans.

Different Molecular Phenotypes of Progression in BRAF- and RAS-Like Papillary Thyroid Carcinoma.

BACKGRUOUND: Papillary thyroid carcinoma (PTC) can be classified into two distinct molecular subtypes, BRAF-like (BL) and RASlike (RL). However, the molecular characteristics of each subtype according to clinicopathological factors have not yet been determined. We aimed to investigate the gene signatures and tumor microenvironment according to clinicopathological factors, and to identify the mechanism of progression in BL-PTCs and RL-PTCs. METHODS: We analyzed RNA sequencing data and corresponding clinicopathological information of 503 patients with PTC from The Cancer Genome Atlas database. We performed differentially expressed gene (DEG), Gene Ontology, and molecular pathway enrichment analyses according to clinicopathological factors in each molecular subtype. EcoTyper and CIBERSORTx were used to deconvolve the tumor cell types and their surrounding microenvironment. RESULTS: Even for the same clinicopathological factors, overlapping DEGs between the two molecular subtypes were uncommon, indicating that BL-PTCs and RL-PTCs have different progression mechanisms. Genes related to the extracellular matrix were commonly upregulated in BL-PTCs with aggressive clinicopathological factors, such as old age (≥55 years), presence of extrathyroidal extension, lymph node metastasis, advanced tumor-node-metastasis (TNM) stage, and high metastasis-age-completeness of resection- invasion-size (MACIS) scores (≥6). Furthermore, in the deconvolution analysis of tumor microenvironment, cancer-associated fibroblasts were significantly enriched. In contrast, in RL-PTCs, downregulation of immune response and immunoglobulin-related genes was significantly associated with aggressive characteristics, even after adjusting for thyroiditis status. CONCLUSION: The molecular phenotypes of cancer progression differed between BL-PTC and RL-PTC. In particular, extracellular matrix and cancer-associated fibroblasts, which constitute the tumor microenvironment, would play an important role in the progression of BL-PTC that accounts for the majority of advanced PTCs.

Accumulation of 131Iodine in the nasolacrimal sac/duct after radioiodine therapy for papillary thyroid cancer.

SPECT/CT is a powerful tool for assessing unexpected concentrations of radioiodine resulting from benign uptake in organs with sodium-iodide symporter (NIS) expression. We report a case of accumulation of 131Iodine in the nasolacrimal sac/duct after radioiodine therapy for papillary thyroid cancer. A whole-body scan was taken 3 days after the administration of 5.5 GBq of 131Iodine. SPECT/CT images localized the focal tracer uptake in the nasolacrimal sac/duct likely due to nasolacrimal duct obstruction secondary to prior radioiodine or iodine therapies. Hybrid SPECT/CT allows precise anatomical localization and help differentiate benign mimics of disease, which can alter patient management.

Rehabilitación del nervio recurrente laríngeo postiroidectomía / Recurrent laryngeal nerve rehabilitation after thyroidectomy

El carcinoma papilar tiroideo es el tipo de cáncer más común de esta glándula, y su tratamiento de elección es la tiroidectomía. Entre las complicaciones asociadas resalta la parálisis de las cuerdas vocales, la cual ocurre por una lesión directa del nervio laríngeo recurrente durante la cirugía. Se presenta una paciente de 22 años de edad con este diagnóstico, a la cual se le realizó una tiroidectomía total; en el postoperatorio inmediato la paciente comenzó con estridor laríngeo intenso que requirió una traqueotomía de urgencia. En el examen físico se constató una parálisis bilateral de las cuerdas vocales y se decidió comenzar un tratamiento de rehabilitación del nervio recurrente laríngeo con laserterapia y HIVAMAT-200 como modalidades combinadas. Los resultados alcanzados con la fisioterapia fueron satisfactorios y la paciente se reintegró rápidamente a su ámbito familiar, escolar y social.

Papillary thyroid carcinoma is the most common type of cancer of this gland, and its treatment of choice is thyroidectomy. Vocal cord paralysis stands out among the associated complications, in which a direct injury to the recurrent laryngeal nerve occurs during surgery. We present a 22-year-old female patient with this diagnosis, who underwent a total thyroidectomy; in the immediate postoperative period the patient began with intense laryngeal stridor requiring an emergency tracheotomy. Physical examination revealed bilateral vocal cord paralysis and it was decided to begin rehabilitation treatment of the recurrent laryngeal nerve with laser therapy and HIVAMAT-200 as combined modalities. The results achieved with physiotherapy were satisfactory and the patient was quickly reintegrated into her family, school and social environment.

Comparison of ultrasound-guided radiofrequency ablation versus thyroid lobectomy for T1bN0M0 papillary thyroid carcinoma.

OBJECTIVE: To investigate and compare the clinical outcomes between radiofrequency ablation (RFA) and thyroid lobectomy (TL) for T1bN0M0 papillary thyroid carcinoma (PTC). METHODS: This retrospective study evaluated 283 patients with solitary T1bN0M0 PTC treated with RFA (RFA group, 91 patients) or TL (TL group, 192 patients) from May 2014 to November 2018. The patients were regularly followed up after treatment. Local tumor progression, lymph node metastasis (LNM), recurrent tumor, persistent tumor, recurrence-free survival (RFS), treatment variables (hospitalization, procedure time, estimated blood loss, and cost), complication, and delayed surgery were compared. RESULTS: During the follow-up (median [interquartile ranges], 50.4 [18.0] months), no significant differences were found in the local tumor progression (4.4% vs 3.6%, p = 1.000), LNM (1.1% vs 2.1%, p = 0.917), recurrent tumor (2.2% vs 1.6%, p = 1.000), persistent tumor (1.1% vs 0%, p = 0.146), and RFS rate (95.6% vs 96.4%, p = 0.816) in the RFA and TL groups. Distant metastasis was not detected. Patients in the RFA group had a shorter hospitalization (0 vs 7.0 [3.0] days, p < 0.001), shorter procedure time (5.6 [2.9] vs 90.0 [38.5] min, p < 0.001), lower estimated blood loss (0 vs 20 [20] mL, p < 0.001), lower cost ($1972.5 [0.1] vs $2362.4 [1009.3], p < 0.001), and lower complication rate (0 vs 12/192 [6.3%], p = 0.015) than those in the TL group. No patients in the RFA group underwent delayed surgery. CONCLUSIONS: This study revealed comparable 4-year clinical outcomes between RFA and TL for T1bN0M0 PTC in terms of local tumor progression and RFS. As a minimally invasive modality, RFA may be a promising feasible alternative to surgery for the treatment of T1bN0M0 PTC in selected patients after strict evaluation. KEY POINTS: • No significant difference in local tumor progression and RFS was found between RFA and TL for T1bN0M0 PTC during a median follow-up period of 50.4 months. • Compared with TL, RFA led to a shorter hospitalization, lower estimated blood loss, lower cost, and lower complication rate. • RFA may be a promising feasible alternative to surgery for the treatment of T1bN0M0 PTC in selected patients after strict evaluation.

Metastatic diffuse follicular variant papillary thyroid cancer without cervical lymph node metastasis presenting with symptoms related to hypopituitarism

ABSTRACT In this article, we present a case of diffuse follicular variant papillary thyroid carcinoma with pituitary metastasis, which is a rare cause of pituitary metastasis. The follicular variant of papillary thyroid carcinoma is an uncommon variant of papillary carcinoma. A 74-year-old male was presented with weakness, fatigue, and a decreased appetite. The patient was diagnosed with secondary adrenal and thyroid insufficiencies. Imaging revealed a pituitary mass with suprasellar extension, right cavernous sinus invasion, and optic chiasm compression. Thyroid ultrasonography revealed a nodule with a maximum size of 7.2cm in the right lobe. Cytological examination via fine-needle aspiration suggested papillary thyroid cancer. Total thyroidectomy with central and right lateral neck dissection confirmed the diagnosis of diffuse follicular variant of papillary thyroid carcinoma. Owing to visual field defects, the patient underwent transsphenoidal surgery. Histological and immunohistochemical evaluations confirmed pituitary metastasis from the papillary thyroid cancer. Radioactive iodine treatment and gamma knife radiotherapy of the pituitary gland were performed. The initiation of sorafenib treatment was deemed appropriate during the follow-up. A significant decrease in the thyroglobulin levels was observed after sorafenib treatment. Pituitary metastasis should be considered in patients diagnosed with hypopituitarism and pituitary lesions at initial evaluation. The presence of visual field defects may be an indication for neurosurgical intervention and guide both diagnosis and treatment. The management of papillary thyroid cancer and the role of treatment modalities in prognosis depend on the biological behavior of the tumor. Early diagnosis and multidisciplinary management are crucial for the treatment of these patients.