Treatment of "locally advanced" well-differentiated thyroid carcinomas.

PURPOSE: To analyse thyroid carcinomas having an extrathyroid extension in order to identify the principal prognostic factors and outline an effective therapeutic strategy. METHODS: We selected a sample of 160 patients suffering from locally advanced "well differentiated thyroid carcinoma (T4) who had undergone surgery at the Department of Surgery of University of Rome "La Sapienza". The sample was subdivided into three groups: T4, limited type I, and extensive type II, T4 microcarcinomas. RESULTS: We obtained excellent results with the T4 microcarcinomas, above all in patients under the age of 45, with a 94.5% survival rate, compared with 88% in patients aged over 45. In the extensive type II T4 carcinoma we obtained a survival rate of 29.4% in patients aged over 45 years. CONCLUSIONS: Age, combined with an aggressive histological variant (Sclerosing and tall-cell papillary carcinoma), is an important factor in prognosis. The radicality of surgical excision is considered an important prognostic factor, although the results reported in the literature are contradictory. Aggressive surgery can free from the disease a high percentage of patients over the age of 50 even with T4. We deem it fundamental to perform total thyroidectomy in all advanced cases of thyroid neoplasm and to extend neoplasm excision to the adjacent tissues, even involving justified surgical demolition.

Current management of epithelial thyroid neoplasms.

Most patients with thyroid cancer have one of the epithelial carcinomas, either papillary or follicular. While most of these patients have favorable outcomes, an understanding of current methods to evaluate, treat, and follow these patients allows physicians to provide better care and identify those most at risk.

Clinical impact of retinoids in redifferentiation therapy of advanced thyroid cancer: final results of a pilot study.

Differentiated thyroid cancer is a malignant tumour that has a fairly good prognosis, with patients surviving for many years. Multimodal therapy with surgery, radioiodine therapy and TSH suppressive medication is of proven efficacy. However, loss of differentiation is observed in up to one-third of patients with differentiated thyroid cancer, paralleled by an increase in tumour grading and loss of thyroid-specific functions (thyrotropin receptor, iodine accumulation). Such tumours may no longer be amenable to standard treatment protocols, including TSH suppression and radioiodide therapy. Retinoic acids have been shown to exert re-differentiating effects on thyrocytes in various experimental studies and case reports, and it was on this basis that this pilot study was initiated. Patients with advanced thyroid cancer and without the therapeutic options of operation or radioiodide therapy were treated with 13- cis-retinoic acid at a dosage of 1.5 mg/kg body weight daily over 5 weeks. Parameters for assessment of the therapeutic effect were serum thyroglobulin (TG) levels, radioiodine uptake, and tumour size prior to and after retinoid treatment. Fifty patients were evaluated for response, classified as reduction in tumour size and TG levels, stable disease or disease progression. Thirteen patients showed a clear increase in radioiodine uptake, and eight a mild increase. TG levels were unchanged or decreased in 20 patients. Tumour size was assessable in 37 patients; tumour regression was observed in six, and there was no change in 22. In total, a response was seen in 19 patients (38%). Response to retinoid therapy did not always correlate with increased radioiodine uptake, so other direct antiproliferative effects have to be assumed. The encouraging results of the study and the low rate of side-effects with good tolerability of retinoids warrant further studies with altered inclusion criteria and employment of other redifferentiating drugs or combinations of agents.