Successful Treatment of Differentiated Thyroid Carcinoma with Transaxillary Robotic Surgery and Radioiodine: The First European Experience.

OBJECTIVES: Transaxillary robotic thyroidectomy surgery (TARS) has been reported to be a safe approach in patients with differentiated thyroid carcinoma, and oncological responses are promising. STUDY DESIGN: This study aimed to evaluate the oncological outcomes of TARS followed by radioiodine (RAI) therapy in patients with differentiated thyroid carcinoma. Between 2011 and 2016, patients treated for differentiated thyroid carcinoma by TARS in a single institution, followed by RAI, were retrospectively included. The oncological response was performed according to the 2015 American Thyroid Association (ATA) guidelines 6-12 months later and at the last available visit. RESULTS: A total of 42 patients (30 females) were included, with a median tumor size of 20 mm (12 cases of N1a and 5 cases of N1b on initial pathology report). According to ATA classification of recurrence risk after surgery, 17 and 25 patients were classified as low and intermediate risk, respectively. After RAI, all patients had a normal posttherapeutic whole body scan (except 1 patient, who had pathological lymph node uptake), but no unusual uptake was seen. At the 6- to 12-month evaluation (n = 37), 24 patients had excellent response, 8 had indeterminate response, and 5 had incomplete response (2 biological and 3 structural); no distant metastasis was found. At the last evaluation (median follow-up 15.9 months), 35 patients had no evidence of disease and 1 patient had a structural incomplete response. In total, a second open surgery was necessary for 3 patients to treat persistent lymph nodes (all intermediate risk). CONCLUSION: In this study, TARS followed by RAI therapy seems to be curative, even for patients with lymph node metastases, after good preoperative staging. More studies are required to confirm the findings.

Quality of life, clinical outcomes and safety of early prophylactic levothyroxine administration in patients with Graves' hyperthyroidism undergoing radioiodine therapy: a randomized controlled study.

OBJECTIVE: While radioiodine therapy is commonly used for treating Graves' disease, a prolonged and clinical hypothyroidism may result in disabling symptoms leading to deterioration of quality of life (QoL) of patients. Introducing levothyroxine (LT4) treatment in the early post-therapeutic period may be an interesting approach to limit this phenomenon. METHODS: A multicenter, prospective, open-label randomized controlled trial enrolled 94 patients with Graves' hyperthyroidism randomly assigned to the experimental group (n=46) (group A: early prophylactic LT4 treatment) or the control group (n=48) (group B: standard follow-up). The primary endpoint was the 6-month QoL. The secondary endpoints were other QoL scores such as Graves' ophthalmopathy (GO) outcomes, thyroid function tests and safety. RESULTS: The primary endpoint at 6 months was achieved: the mental composite score (MCS) of Short Form 36 (SF-36) was significantly higher in group A compared to group B (P=0.009). Four other dimension scores of the SF-36 and four dimension scores of the thyroid-specific patient-reported outcome (ThyPRO) significantly differed between the two groups, indicating better QoL in group A. After adjustment for variables, the early LT4 administration strategy was found as an independent factor for only two scores of SF-36: the MCS and the general health (GH) score. There were no differences in GO, final thyroid status and changes in the anti-TSH receptor antibodies (TRAbs) levels between the two groups. No adverse cardiovascular event was reported. CONCLUSION: Early LT4 administration post-radioactive iodine (RAI) could represent a safe potential benefit for patients with regard to QoL. The optimal strategy taking into account administered RAI activities and LT4 treatment dosage and timing remains to be determined.

Additional diagnostic value of hybrid SPECT-CT systems imaging in patients with differentiated thyroid cancer.

AIM: : Nuclear medicine has entered a new era of multimodality imaging. Single-photon emission computed tomography/computed tomography (SPECT/CT) hybrid cameras are relatively new diagnostic tools that have been widely adopted and are present in most nuclear medicine units. SPECT/CT instruments allow functional and morphologic images to be acquired as superimposed (fusion images) in a single session. METHODS: The integration of CT enables better characterization of functional abnormalities identified on planar and SPECT scintigraphy by offering structural information. It thus highly improves accuracy compared with conventional scintigraphy. RESULTS AND CONCLUSIONS: The combination of functional information and anatomic localization has the potential to influence medical practice with newer imaging algorithms. This review presents the current evidence and potential indications of SPECT/CT imaging in the initial staging, treatment, and follow-up of patients with differentiated thyroid cancer.

Is thyroid cancer recurrence risk increased after transplantation?

CONTEXT: An increased cancer mortality is reported in transplanted patients. OBJECTIVE: This multicentric study aimed to investigate the rate of thyroid cancer recurrence after transplantation. RESULTS: Sixty-eight patients (35 male/33 female) with a history of both thyroid cancer and organ transplantation were recruited via two nationwide French networks. Histological analysis identified 58 papillary (88%), 5 follicular (7.5%), and 3 poorly differentiated cancer cases (4.5 %). Thirty-one patients (52%) presented high recurrence risk tumors. In the 36 patients with thyroid cancer diagnosed after transplantation, the 5-year disease-free survival (DFS) was 74.7% (SE: 7.3%). One patient died after progression of a poorly differentiated cancer. Persistent disease was observed in six high-risk patients. One of them underwent a second transplantation and disease remained stable after 5 years of follow-up. Thyroid cancer had been diagnosed before transplantation in 32 patients. One patient with cystic fibrosis and thyroid lung metastases at the time of lung transplantation underwent a 4-year remission. For the 31 patients in remission at the time of transplantation, the 5-year DFS was 93.1% (SE: 4.8%). Two patients with local recurrence presented subsequent remission. For the entire study population, the 5-year and 9-year DFS were 81.9% (SE: 5.5%) and 75.6% (SE: 7.9%), respectively. Recurrence or persistent disease occurred in patients with high-risk tumors. CONCLUSIONS: The prognosis of thyroid cancer does not seem to be altered by transplantation. This suggests that a history of thyroid cancer should not be considered a contraindication.

Fatal heart failure after a 26-month combination of tyrosine kinase inhibitors in a papillary thyroid cancer.

BACKGROUND: Patients with progressive refractory thyroid cancer are potential candidates for clinical trials using tyrosine kinase inhibitors (TKIs), and a promising proportion of patients in these trials have achieved stable disease. Here we report an unusual adverse experience in a patient receiving a combination of TKIs. SUMMARY: The patient was a 62-year-old man with chronic myloid leukemia (CML) and thyroid carcinoma that did not concentrate iodide and had metastases. He was started on imatinib for his CML. About 5 months later he was started on sorafenib for his thyroid cancer. At this time he had no risk factors for cardiac disease except moderate obesity. He had a complete cytogenetic response in his CML, and a partial response in his thyroid cancer. Twenty-one months after starting the combination of TKIs, he manifested signs of coronary artery disease. He received a combination of medications and his TKIs were continued. He died of a sudden myocardial infarction with cardiogenic shock 28 months after starting the combination of TKIs. A retrospective analysis of sequential 18-fludeoxyglucose positron emission tomography scans (18-FDG PET scans) were indicative of cardiac toxicity developing during the period of concomitant administration of TKIs. CONCLUSION: We report the first case of apparent lethal cardiotoxicity with imatinib-sorafenib combined therapy. Combination TKI treatment may enhance the risk of adverse effects. Our experience with this patient suggests that cardiac PET scan should be monitored closely in these type of patients.