Long-Term Outcomes Following Therapy in Differentiated Thyroid Carcinoma: NTCTCS Registry Analysis 1987-2012.

CONTEXT: Initial treatments for patients with differentiated thyroid cancer are supported primarily by single-institution, retrospective studies, with limited follow-up and low event rates. We report updated analyses of long-term outcomes after treatment in patients with differentiated thyroid cancer. OBJECTIVE: The objective was to examine effects of initial therapies on outcomes. DESIGN/SETTING: This was a prospective multi-institutional registry. PATIENTS: A total of 4941 patients, median follow-up, 6 years, participated. INTERVENTION: Interventions included total/near-total thyroidectomy (T/NTT), postoperative radioiodine (RAI), and thyroid hormone suppression therapy (THST). MAIN OUTCOME MEASURE: Main outcome measures were overall survival (OS) and disease-free survival using product limit and proportional hazards analyses. RESULTS: Improved OS was noted in NTCTCS stage III patients who received RAI (risk ratio [RR], 0.66; P = .04) and stage IV patients who received both T/NTT and RAI (RR, 0.66 and 0.70; combined P = .049). In all stages, moderate THST (TSH maintained subnormal-normal) was associated with significantly improved OS (RR stages I-IV: 0.13, 0.09, 0.13, 0.33) and disease-free survival (RR stages I-III: 0.52, 0.40, 0.18); no additional survival benefit was achieved with more aggressive THST (TSH maintained undetectable-subnormal). This remained true, even when distant metastatic disease was diagnosed during follow-up. Lower initial stage and moderate THST were independent predictors of improved OS during follow-up years 1-3. CONCLUSIONS: We confirm previous findings that T/NTT followed by RAI is associated with benefit in high-risk patients, but not in low-risk patients. In contrast with earlier reports, moderate THST is associated with better outcomes across all stages, and aggressive THST may not be warranted even in patients diagnosed with distant metastatic disease during follow-up. Moderate THST continued at least 3 years after diagnosis may be indicated in high-risk patients.

Unique characteristics and outcomes of patients diagnosed with both primary thyroid and primary renal cell carcinoma.

OBJECTIVE: Patients with multiple primary malignancies may exhibit unique clinical characteristics that suggest a common predisposition or lead to different disease management. Given the association of primary thyroid (TC) and renal cell carcinoma (RCC), we characterized the clinicopathologic features of patients treated for both malignancies (TC/RCC). METHODS: TC/RCC patients were identified through the institutional tumor registry and using data compiled by retrospective chart review. To compare with broader institutional and national cohorts, we examined patients admitted with TC or RCC institution-wide and reviewed the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program for these cancers. RESULTS: Overall, 51% of patients developed TC before RCC, 27% developed RCC before TC, and 22% were diagnosed within 1 year of each other. The mean age at TC diagnosis was 52 ± 15 (18-77), which was significantly older than institutional TC patients (45 ± 16.5 years, P≤.0001), and the mean age at RCC diagnosis was 59 ± 12 (32-79). The TC/RCC cohort had a balanced sex distribution (51% female) compared with the institutional TC group (67% female, P = .0003) and the institutional RCC group (31% female, P<.0001). Similar age and sex ratio differences were seen when compared with SEER cohorts. In the TC/RCC cohort, 43% of patients developed other cancers (52% of females, 33% of males; P = .04); among the females, 45% developed breast cancer. CONCLUSION: Individuals who develop both TC and RCC may represent a unique subset of cancer patients. Further prospective research is warranted to explore the unanticipated association with breast cancer in female patients and to investigate a possible common pathogenesis underlying these malignancies.

The noninvestigational use of tyrosine kinase inhibitors in thyroid cancer: establishing a standard for patient safety and monitoring.

CONTEXT: The increasing use of tyrosine kinase inhibitor therapy outside of the context of the clinical trial for treatment of advanced thyroid cancer has highlighted the need for a systematic approach to the clinical application of these agents in order to improve patient safety and monitoring promote consistency among providers, and ensure compliance with both institutional and industry standards. EVIDENCE: We reviewed professional thyroid cancer guidelines, the National Comprehensive Cancer Network task force reports, American Society of Clinical Oncology safety standards, review articles, and clinical trials published within the past 10 yr and also included relevant older studies. CONCLUSIONS: Review of available published data and the collective experience prescribing tyrosine kinase inhibitors at The University of Texas MD Anderson Cancer Center have highlighted the need for a systematic, comprehensive, and uniform approach to managing these patients. This paper discusses the approach adopted by the Department of Endocrine Neoplasia at the MD Anderson Cancer Center and illustrates practice patterns, experience, and our standardized approach related to prescribing commercially available tyrosine kinase inhibitors outside of the context of a clinical trial for patients with advanced thyroid cancer.

Surviving the storm: two cases of thyroid storm successfully treated with plasmapheresis.

Thyroid storm is a rare, but critical, illness that can lead to multiorgan failure and carries a high death rate. The following case series describes two adult men with Graves' disease who presented in thyroid storm and either failed or could not tolerate conventional medical management. However, both patients responded well to plasmapheresis, which resulted in clinical and biochemical stabilisation of their disease processes. The treatment option of plasmapheresis should be considered as a stabilising measure, especially when patients have failed or cannot tolerate conventional therapy. Plasmapheresis leads to amelioration of symptoms and a significant decline in thyroid hormone levels, providing a window to treat definitively with thyroidectomy.

Durable effect of radioactive iodine in a patient with metastatic follicular thyroid carcinoma.

Objective. Thyroid cancer is the most common endocrine malignancy and fastest increasing of all cancers in both men and women in the United States. Traditionally, differentiated thyroid cancer (DTC) carries a good prognosis when diagnosed early, but increasingly patients are presenting with late-stage disease and bone metastasis which carries a poor prognosis. Treatment of DTC involves surgical resection followed by radioactive iodine (RAI), which conventionally is thought to reach maximal effectiveness between 6 and 12 months following treatment. We report a case and review the literature surrounding long-term effect of radioactive iodine treatment in metastatic thyroid carcinoma. Methods. Patient clinical encounter and the literature review. Results. We describe a 49-year-old woman with symptomatic metastatic follicular thyroid cancer (FTC) to the spine and radiographic evidence of spinal cord compression who was effectively treated with RAI. Her initial serum thyroglobulin (Tg) levels following total thyroidectomy were 1,343 ng/mL which dramatically dropped to less than 100 ng/mL following RAI. Forty-three months following treatment with RAI, she has experienced complete resolution of her symptoms and continues to maintain persistently low-thyroglobulin levels of less than 100 ng/mL. Conclusions. RAI is believed to reach peak efficacy within 6-12 months; however, little has been reported regarding the long-term duration of benefit. This case demonstrates that the benefits of RAI therapy may be enduring, even in patients with widely metastatic thyroid cancer. It suggests in clinically stable patients with declining thyroglobulin after treatment, that there may not be an immediate need for additional therapy as RAI treatment may provide lasting effects.

Repeat pulmonary resection for metachronous colorectal carcinoma is beneficial.

BACKGROUND: Initial pulmonary metastatectomy for limited colorectal carcinoma metastases is associated with improved survival. The role of repeat thoracic interventions is less well defined. The purpose of this study is to clarify the role of repeat pulmonary resection for metastatic colorectal carcinoma. METHODS: A retrospective study was performed using patients who underwent pulmonary metastatectomy for colorectal carcinoma at a single academic institution between January 1, 1985, and December 31, 2007. Sex, age at colorectal operation, colorectal TNM stage, and operative procedures for pulmonary metastases were recorded. Intervals between the original colorectal operation and thoracic operation and between the first pulmonary metastatectomy and repeat thoracic interventions were calculated. Log-rank comparison of Kaplan-Meier survival curves and covariate analysis were performed. RESULTS: A total of 69 patients were identified as having undergone at least 1 pulmonary metastatectomy. There were 32 female and 37 male patients with a mean age of 57 +/- 11 years. The median disease-free interval from original colorectal operation to first pulmonary metastatectomy for all the patients was 27 months. A total of 125 pulmonary resections were performed: 64 wedge resections, 27 segmentectomies, 30 lobectomies, and 4 pneumonectomies. Of the 69 patients, 41 underwent a single thoracic metastatectomy, whereas 28 underwent at least 1 second thoracic metastatectomy (2nd, 17 patients; 3rd, 6; 4th, 4; 5th, 1). There were no perioperative mortalities. From the original colorectal resection, the 5-year survival was 59% (median, 52 months). From the initial pulmonary metastatectomy, the 5-year survival for all patients was 25% (median, 36 months). The 5-year survival for patients undergoing only 1 thoracic resection was 23% (median, 24 months), which was not significantly different compared to patients undergoing repeat thoracic resections, 29% (median: 42 months). In the covariate analysis, no parameters significantly impacted survival. CONCLUSIONS: Patients undergoing multiple pulmonary resections have the same survival as patients undergoing a single pulmonary resection for metachronous colorectal carcinoma. These findings indicate pulmonary metastases may be favorably treated with repeat thoracic interventions.