Differentiated Thyroid Carcinoma Long-Term Prognostic Factors.

Introduction: Thyroid cancer is the most common cancer in women in Ecuador. Objective: The aim of this study was to determine the demographics and clinical and treatment variables of patients with papillary or follicular thyroid cancer, referred to as differentiated thyroid cancer (DTC), treated at a third-level hospital in Quito, Ecuador. Methods: We reviewed retrospectively the medical records of patients with DTC, who underwent surgical treatment, from 1990 to 2019. Data included demographics, pathological information, clinical stage, type of surgery, and radioactive iodine (RAI) adjuvant therapy. Patients were monitored for up to 29 years (median follow-up time 6.9 years). Results: The corrected overall 5-, 10-, 20-, and 30-year survival rates (Kaplan-Meier) were 93%, 85%, 70%, and 63%, respectively. On univariate analysis, age, histological type, tumor grade, histological variants, capsular invasion, vascular invasion, tumor size, clinical stage, distant metastases at diagnosis, surgical margins, extrathyroidal invasion, radioactive iodine adjuvant treatment, and locoregional recurrence were found to be significant prognostic factors. In a multivariate analysis, the following independent variables: age over 55 years, extrathyroidal spread, metastasis at diagnosis, and stage II to IV raised the risk of death (hazard risk) (HR). Conclusions: Age over 55 years, extrathyroidal spread, metastasis at diagnosis, and advanced clinical stage were found to have a harmful prognosis and an increased risk of death in a series of Ecuadorian patients surgically treated for a DTC.

Active surveillance is a feasible and safe strategy in selected patients with papillary thyroid cancer and suspicious cervical lymph nodes detected after thyroidectomy.

Objective: After initial treatment, up to 30% of patients with papillary thyroid cancer (PTC) have incomplete response, mainly cervical lymph node (LN) disease. Previous studies have suggested that active surveillance (AS) is a possible option for these patients. Our aim was to report the results of AS in patients with PTC and cervical LN disease. Materials and methods: In this retrospective observational study, we included adult patients treated and followed for PTC, who presented with cervical LN disease and were managed with AS. Growth was defined as an increase ≥ 3mm in either diameter. Results: We included 32 patients: 27 (84.4%) women, age of 39 ± 14 years, all initially treated with total thyroidectomy, and 22 (69%) with therapeutic neck dissection. Cervical LN disease was diagnosed 1 year (0.3-12.6) after initial management, with a diameter of 9.0 mm (6.0-19.0). After a median AS of 4.3 years (0.6-14.1), 4 (12.5%) patients had LNgrowth: 2 (50%) of whom were surgically removed, 1 (25%) was effectively treated with radiotherapy, and 1 (25%) had a scheduled surgery. Tg increase was the only predictive factor of LN growth evaluated as both the delta Tg (p < 0.0366) and percentage of Tg change (p < 0.0140). None of the included patients died, had local complications due to LN growth or salvage therapy, or developed distant metastases during follow-up. Conclusion: In selected patients with PTC and suspicious cervical LNs diagnosed after initial treatment, AS is a feasible and safe strategy as it allows effective identification and treatment of the minority of patients who progress.

Predictors of recurrence after total thyroidectomy in 1,611 patients with papillary thyroid carcinoma: postoperative stimulated serum thyroglobulin and ATA initial and dynamic risk assessment.

Objective: Despite a favorable prognosis, some patients with papillary thyroid carcinoma (PTC) develop recurrence. The objective of this study was to examine the impact of the combination of initial American Thyroid Association (ATA) risk stratification with serum level of postoperative stimulated thyroglobulin (s-Tg) in predicting recurrence in patients with PTC and compare the results with an assessment of response to initial therapy (dynamic risk stratification). Subjects and methods: We retrospectively analyzed 1,611 patients who had undergone total thyroidectomy for PTC, followed in most cases (87.3%) by radioactive iodine (RAI) administration. Clinicopathological features and s-Tg levels obtained 3 months postoperatively were evaluated. The patients were stratified according to ATA risk categories. Nonstimulated thyroglobulin levels and imaging studies obtained during the first year of follow-up were used to restage the patients based on response to initial therapy. Results: After a mean follow-up of 61.5 months (range 12-246 months), tumor recurrence was diagnosed in 99 (6.1%) patients. According to ATA risk, recurrence was identified in 2.3% of the low-risk, 9% of the intermediate-risk, and 25% of the high-risk patients (p < 0.001). Using a receiver operating characteristic curve approach, a postoperative s-Tg level of 10 ng/mL emerged as the ideal cutoff value, with positive and negative predictive values of 24% and 97.8%, respectively (p < 0.001). Patients with low to intermediate ATA risk with postoperative s-Tg levels < 10 ng/mL and excellent response to treatment had a very low recurrence rate (<0.8%). In contrast, higher recurrence rates were observed in intermediate-riskto high-risk patients with postoperative s-Tg > 10 ng/mL and indeterminate response (25%) and in those with incomplete response regardless of ATA category or postoperative s-Tg value (38.5-87.5%). Using proportion of variance explained (PVE), the predicted recurrence using the ATA initial risk assessment alone was 12.7% and increased to 29.9% when postoperative s-Tg was added to the logistic regression model and 49.1% with dynamic risk stratification. Conclusion: The combination of ATA staging system and postoperative s-Tg can better predict the risk of PTC recurrence. Initial risk estimates can be refined based ondynamic risk assessment following response to therapy, thus providing a useful guide for follow-up recommendations.

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

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.

Is radioiodine ablation with 1.1 GBq (30 mCi) 131I necessary in low-risk thyroid cancer patients? Results from a long-term follow-up prospective study.

BACKGROUND: In patients with low-risk differentiated thyroid cancer (DTC), remnant ablation with radioiodine (RA) after total thyroidectomy (TT) is controversial. No benefits have been demonstrated in terms of mortality or disease-free survival. Recent evidence found that RA did not improve mid-term outcomes. PURPOSE: To evaluate initial response to treatment and long-term follow-up status in low-risk DTC patients after TT vs. TT + RA with 131I 1.11 GBq (30 mCi). METHODS: Prospective multicenter non-randomized study; 174 low-risk DTC that underwent TT were recruited an divided in two groups according to RA (87 ablated and 87 non-ablated). Response to treatment was evaluated at 6-18 months after thyroidectomy and at the end of follow-up with measurements of thyroglobulin, and anti-thyroglobulin antibodies levels, and neck ultrasonography. RESULTS: Baseline characteristics of both groups were similar. Ablated patients: median age 45.5 years, 84% females, 95.4% papillary thyroid carcinoma (PTC), mean tumor size 16 mm; non-ablated: median age 45 years, 88.5% females, 96.6% PTC, mean tumor size 14 mm. Response to initial treatment was similar between both groups, with < 2% of structural incomplete response. Final status was evaluated in 139 cases (median follow-up of 60 months). Among ablated patients, 82.8% had no evidence of disease (NED), 12% had an indeterminate response (IR) and 5% a biochemical incomplete response (BIR). Non-ablated patients had NED in 90%, IR in 8.7% and BIR in 1.2%. No statistical difference was found between groups (p = 0.29). No patient had evidence of structural disease at the end of follow-up. CONCLUSIONS: Our findings support the recommendation against routine RA in low-risk DTC patients.

Treatment strategies for low-risk papillary thyroid carcinoma: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM).

Increasingly sensitive diagnostic methods, better understanding of molecular pathophysiology, and well-conducted prospective studies have changed the current approach to patients with thyroid cancer, requiring the implementation of individualized management. Most patients with papillary thyroid carcinoma (PTC) are currently considered to have a low risk of mortality and disease persistence/recurrence. Consequently, current treatment recommendations for these patients include less invasive or intensive therapies. We used the most recent evidence to prepare a position statement providing guidance for decisions regarding the management of patients with low-risk PTC (LRPTC). This document summarizes the criteria defining LRPTC (including considerations regarding changes in the TNM staging system), indications and contraindications for active surveillance, and recommendations for follow-up and surgery. Active surveillance may be an appropriate initial choice in selected patients, and the criteria to recommend this approach are detailed. A section is dedicated to the current evidence regarding lobectomy versus total thyroidectomy and the potential pitfalls of each approach, considering the challenges during long-term follow-up. Indications for radioiodine (RAI) therapy are also addressed, along with the benefits and risks associated with this treatment, patient preparation, and dosage. Finally, this statement presents the best follow-up strategies for LRPTC after lobectomy and total thyroidectomy with or without RAI.

Active Surveillance of Small Metastatic Lymph Nodes as an Alternative to Surgery in Selected Patients with Low-Risk Papillary Thyroid Cancer: A Retrospective Cohort Study.

Background: It has been suggested that small metastatic lymph nodes (LNs) detected after initial surgery in patients with differentiated thyroid cancer (DTC) can be managed with active surveillance (AS). However, there is still concern regarding the clinical outcomes of these patients. The main aims of our study were as follows: (1) to assess the frequency of growth and the need of additional treatment in a group of patients with LN recurrences selected for AS, and (2) to determine predictive factors of LN progression. Methods: We retrospectively reviewed 856 clinical records from our DTC patient's database (May 2010 to January 2022). Eighty patients had suspicious cervical LNs on consecutive ultrasound (US) after initial surgery, but we included 50 patients with cytological confirmation of metastatic disease and at least 12 months follow-up. Exclusion criteria were as follows: any LN ≥2 cm or multiple LNs ≥1.5 cm in size, proximity to vital structures, PET-positive disease (standard uptake value ≥5), aggressive histology, and distant metastasis. Patients were followed with thyroglobulin (Tg) and thyroglobulin antibodies measurements on suppressive therapy and neck US every 6-12 months. LN growth was defined as an increase of ≥3 mm in any of its diameters. Results: A total of 50 patients had a median age of 41 years (range, 18-75). Most patients were women (80%) and had classical papillary thyroid cancer (86%). The mean size of the LNs was 10.1 ± 4.4 mm. After a median follow-up of 29 months (range, 12-144), 12 patients (24%) had an increase in size of the metastatic LN, 7 (58%) of whom were surgically removed. None of these seven patients had a structural incomplete response at the end of follow-up. The only variable that predicted an increase in LN size was a rise in Tg levels ≥0.5 ng/mL (p = 0.016). Based on a multivariate analysis, patients with increase in Tg levels ≥0.5 ng/mL had a significantly higher chance of developing LN growth (odds ratio [OR] 16.2 [confidence interval, CI 1.5-120.2], p = 0.020). The median progression-free survival rate was 6.6 years [CI 5.6-9.5]. Conclusion: AS of small LNs could be a feasible alternative to immediate surgery in properly selected patients.

Benign and malignant thyroid nodules with autoimmune thyroiditis.

Objective: The prevalence of autoimmune thyroiditis (AT) in papillary thyroid carcinoma (PTC) is still controversial. The aim of this study was to investigate the frequency of coexistence of PTC with AT versus that of the coexistence of benign nodules with AT. Materials and methods: This was a cross-sectional retrospective study including patients operated on for thyroid nodules from January 2011, to April 2021. The frequency of papillary carcinomas cooccurring with AT was compared to that of benign nodules cooccurring with AT, which was assessed based on cytopathological diagnosis after thyroidectomy. Results: The study included 668 cases of benign nodules and 420 cases with PTC. No statistically significant difference was observed between cases of benign and PTC nodules regarding the presence of AT (25% vs. 28%, respectively, p = 0.177). The size of the PTC compared to that of the benign predominant nodules was significantly smaller both in the absence (0.96 ± 1.09 cm vs. 2.19 ± 1.06 cm, p < 0.05) and in the presence (0.77 ± 0.76 cm vs. 1.67 ± 1.08 cm, p < 0.01) of AT. In the binary logistic regression analysis of the PTC, the only variable associated with AT was multifocality (odds ratio: 1.750, 95% confidence intervals: 1.131-2.706, p = 0.013). The incidences of lymph node involvement and advanced stage PTC were very low both in the presence and absence of AT. Conclusion: The nodules present with PTC were not more likely to coexist with AT than benign nodules were. The small incidence of advanced PTC indicates a significant improvement in early-stage diagnosis.

Natural history, predictive factors of apparent disease (structural or biochemical) and spontaneous excellent response in patients with papillary thyroid carcinoma and indeterminate response to initial therapy with radioiodine.

BACKGROUND: About 20% of patients with papillary thyroid carcinoma (PTC) submitted to total thyroidectomy followed by radioactive iodine (RAI) exhibit an indeterminate response to therapy. The aim was to evaluate the natural history, predictive factors of apparent disease (structural or biochemical), and spontaneous excellent response in patients with PTC and an initial indeterminate response to RAI therapy defined based on unstimulated Tg (u-Tg). METHODS: We evaluated 164 patients who were initially treated with total thyroidectomy and RAI and who had an indeterminate response to therapy (u-Tg between 0.2 and 1 ng/ml, undetectable anti-Tg antibodies [TgAb], and neck ultrasonography [US] without anomalies). None of the patients received empirical therapy with RAI. The patients were followed up for 24 to 144 months (median 72 months). RESULTS: Apparent disease occurred in 16 patients (9.7%), including 13 with structural disease and 3 with u-Tg elevation > 1 ng/ml, but no tumor was detected by the imaging methods (biochemical disease). A higher frequency of disease was observed in patients with >3 lymph node metastases (LNM) and initial u-Tg >0.35 ng/ml. The frequency was only 2% among patients with ≤3 LNM and u-Tg ≤0.35 ng/ml and 9.7% among patients with > 3 LNM or u-Tg >0.35 ng/ml, while the frequency was 27% in patients with >3 LNM and u-Tg >0.35 ng/ml. In the absence of any additional therapy, u-Tg was <0.2 ng/ml (excellent response) in the last assessment in 70 patients (42.7%). Only initial u-Tg was associated with a higher probability of spontaneously achieving an excellent response: 40/72 patients (55.5%) with u-Tg ≤0.35 ng/ml versus 30/92 patients (32.6%) with u-Tg >0.35 ng/ml. CONCLUSIONS: A minority of patients with PTC and an initial indeterminate response to RAI defined based on u-Tg develop apparent disease (structural or biochemical) and many spontaneously achieve an excellent response. The risk of disease can be refined based on parameters such as the extent of lymph node involvement and initial Tg concentration.

Prophylactic Central Neck Lymph Node Dissection in Low-risk Thyroid Carcinoma Patients Does Not Decrease the Incidence of Locoregional Recurrence: A Meta-analysis of Randomized Trials.

OBJECTIVE: To evaluate the effectiveness of T + prophylactic CND (T+CND) compared to T alone on locoregional recurrence in patients with PTC. SUMMARY BACKGROUND DATA: Few RCTs have assessed the risks and benefits of prophylactic CND in patients with PTC. Most recommendations are still based on meta-analyses that include observational studies, which are prone to selection bias. METHODS: We included RCTs involving adult patients with clinically negative neck (cN0) PTC that compared T versus T+CND. The main outcomes assessed were structural and biochemical recurrence and complications. For methodological quality assessment, we used the Revised Cochrane risk-of-bias tool for randomized trials instrument, and for robustness, we used the fragility index. RESULTS: Five RCTs with 763 patients were included (354 in the T group and 409 in the T+CND group). Most studies were classified as having a low risk of bias. Publication bias was not found. Structural recurrence occurred in 11/409 (2.7%) patients in the T+CND group and 9/354 (2.5%) patients in the T group, with a risk difference (RD) =0% [95% confidence interval (CI) -2% to 2%]. For biochemical recurrence, the RD was 0% (95% CI -5% to 4%). The number needed to treat was 500. The rate of permanent hypoparathyroidism was higher in the T+CND group than in the T group [RD 3% (95% CI 0%-6%)]. CONCLUSIONS: We did not find a beneficial effect of prophylactic CND associated with T on locoregional or biochemical recurrence but did confirm a higher risk of permanent hypoparathyroidism associated with this procedure.

Surgical treatment of pediatric and adolescent papillary thyroid cancer: a retrospective study of 54 patients in a single center.

OBJECTIVE: In 2015, American Thyroid Association (ATA) issued the first version of Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer. The purpose of this study is to evaluate whether the ATA pediatric guidelines recommended surgical approach for the patient can be applied to surgical treatment of pediatric PTC in China. METHOD: From April 2012 to December 2020, clinical data of children (≤18 years) with PTC consecutively admitted and treated with initial surgery in the study's department were retrospectively reviewed. RESULTS: The authors found that the central lymph node metastasis (CLNM) rate was significantly higher than that in the lateral neck (83.33 % vs 62.96%, χ2 = 5.704, p = 0.017) .The lymph node metastasis rate was significantly lower in cN1b (-) patients than in cN1b (+) patient (55.00% vs 100.00%, χ2 = 15.263, p = 0.000); Meanwhile, the CLNM and LLNM rates of ipsilateral were significantly higher than those of contralateral central compartment (83.33༅vs 57.41༅%, χ2 = 8.704, p = 0.003). Lymph nodes of 51 lateral lymph node dissection (LND) were analyzed, which revealed the LNM rate of cN1b (-) patients was significantly lower than that of cN1b (+) patients (55.00% vs. 100.00%, χ2 = 15.263, p = 0.000). CONCLUSION: Children and adolescents have a higher rate of lymph node metastasis at the time of diagnosis. TT should be conducted in the majority of children with PTC. CND should be routinely performed; therapeutic LND is recommended for children with cN1b (+).

Indication for radioactive iodine in patients with papillary thyroid carcinoma without apparent disease after total thyroidectomy but with elevated antithyroglobulin antibodies.

OBJECTIVE: To evaluate a criterion for the selective indication of radioactive iodine (RAI) based on the short-term behaviour of antithyroglobulin antibodies (TgAb) in patients with papillary thyroid carcinoma (PTC) who have negative thyroglobulin (Tg) and neck ultrasonography (US) without abnormalities after total thyroidectomy but elevated TgAb. DESIGN: This was a prospective study that evaluated 216 patients with low- or intermediate-risk PTC who had nonstimulated Tg ≤ 0.2 ng/ml and no US abnormalities but elevated TgAb 3 months after thyroidectomy. RAI was not indicated in patients with negative TgAb or a >50% reduction in TgAb concentrations 6 months after initial assessment followed by a negative test or an additional reduction (also >50%) after 12 months. RESULTS: Only two of the 114 patients who did not receive RAI developed recurrences; another 108 patients met the criterion of an excellent response to therapy in the last assessment and TgAb persisted in four patients but there was an additional reduction in their concentration during follow-up. Among the 102 patients who received RAI, post-therapy whole-body scanning (RxWBS) detected persistent disease in 8 (8%). Two of the 94 patients without persistent disease on RxWBS developed recurrences. In the last assessment, in the absence of additional treatment, 54/92 patients (58.7%) without structural recurrence had negative TgAb. CONCLUSIONS: The indication for RAI can be based on the short-term behaviour of TgAb in patients with PTC and elevated TgAb after thyroidectomy who are not high risk and who do not have apparent disease (nonstimulated Tg ≤ 0.2 ng/ml and no US abnormalities).

Current therapeutic options for low-risk papillary thyroid carcinoma: Scoping evidence review.

Most cases of thyroid carcinoma are classified as low risk. These lesions have been treated with open surgery, remote access thyroidectomy, active surveillance, and percutaneous ablation. However, there is lack of consensus and clear indications for a specific treatment selection. The objective of this study is to review the literature regarding the indications for management selection for low-risk carcinomas. Systematic review exploring inclusion and exclusion criteria used to select patients with low-risk carcinomas for treatment approaches. The search found 69 studies. The inclusion criteria most reported were nodule diameter and histopathological confirmation of the tumor type. The most common exclusions were lymph node metastasis and extra-thyroidal extension. There was significant heterogeneity among inclusion and exclusion criteria according to the analyzed therapeutic approach. Alternative therapeutic approaches in low-risk carcinomas can be cautiously considered. Open thyroidectomy remains the standard treatment against which all other approaches must be compared.

Metástasis cervical de cáncer papilar oculto de tiroides: reporte de casos / Cervical metastasis from occult papillary thyroid cancer: case report

El microcarcinoma papilar de tiroides es definido como un tumor de un cm o menos de diámetro mayor. La mayoría permanecen ocultos clínicamente, siendo un hallazgo en autopsias hasta en 36%. La presentación oculta ocurre hasta en un 10 a 26% de todas las neoplasias malignas de tiroides y se define como la presencia de ganglios metastásicos de carcinoma papilar de tiroides en ausencia de lesión primitiva tiroidea evidente durante la exploración clínica y ecográfica. El objetivo de este trabajo es el reporte de dos casos donde el diagnóstico de cáncer de tiroides se realizó a través de su presentación metastásica cervical, siendo el estudio anatomopatológico de la pieza de resección quirúrgica el que devela la presencia de un microcarcinoma papilar. Si bien el tratamiento del de estas lesiones es controversial, existen elementos que sellan la necesidad de resolución quirúrgica. En el debut metastásico ganglionar cervical, está indicada la tiroidectomía total con el vaciamiento ganglionar cervical radical modificado ipsilateral y central. El raidioyodo postquirúrgico será empleado en forma complementaria ante la persistencia, recurrencia o elementos de alto riesgo.

Papillary thyroid microcarcinoma is defined as a tumor one cm or less in diameter. Most remain clinically hidden, being an autopsy finding in up to 36%. Occult presentation occurs in up to 10% to 26% of all thyroid malignancies and is defined as the presence of metastatic nodes from papillary thyroid carcinoma in the absence of a primitive thyroid lesion evident on clinical and ultrasound examination. The objective of this work is the report of two cases where the diagnosis of thyroid cancer was made through its cervical metastatic presentation, being the pathological study of the surgical resection specimen that reveals the presence of a papillary microcarcinoma. Although the treatment of these lesions is controversial, there are elements that seal the need for surgical resolution. In cervical lymph node metastatic debut, total thyroidectomy with modified ipsilateral and central radical cervical lymph node dissection is indicated. Post-surgical radiation iodine will be used in a complementary way in the event of persistence, recurrence or high-risk elements.

Variante células altas de cáncer papilar de tiroides: reporte de casos / Tall cell variant of papillary thyroid cancer: case report

El cáncer papilar constituye aproximadamente el 80% de todos los casos de cáncer de tiroides y el 85% de los tumores diferenciados. La variante de células altas representa el 1,3 al 12% del cáncer papilar siendo la variante agresiva más común de estos tumores. Posee un comportamiento agresivo, con mayor incidencia de invasión extratiroidea, linfovascular y metástasis a distancia, responsables de tasas de recurrencia más altas y peor pronóstico. Los casos aquí reportados reflejan las características que hacen sospechar mayor agresividad tumoral, desde el diagnóstico. Describimos dos pacientes de sexo femenino, entre 40 y 50 años, con historia de corta evolución, cuya presentación fue con síntomas de compresión locorregional y adenopatías metastásicas en cuello. Con hallazgos ecográficos e intraoperatorios de relevancia en cuanto la agresividad tumoral que hicieron sospechar la presencia de una variante agresiva del cáncer papilar. La histopatología de la variante de células altas posee una base molecular diferente respecto al papilar clásico que le confiere mayor morbi-mortalidad, constituyendo un factor de pronóstico independiente para la recurrencia. El tratamiento quirúrgico es la tiroidectomía total con vaciamiento profiláctico de los ganglios linfáticos centrales y eventualmente vaciamiento lateral de cuello según valoración preoperatoria, con posterior ablación postoperatoria de restos tiroideos mediante yodo radiactivo.

Papillary cancer constitutes approximately 80% of all thyroid cancer cases and 85% of differentiated tumors. The tall cell variant represents 1.3 to 12% of papillary cancers, being the most common aggressive variant of these tumors. It has an aggressive behavior, showing a higher incidence of extrathyroid and lymphovascular invasion and distant metastasis, responsible for higher recurrence rates and a worse prognosis. The cases reported here reflect characteristics that make us suspect tumor aggressiveness. These are female patients, between 40 and 70 years old, with a history of short evolution. They present locoregional symptoms or metastatic adenopathies, with ultrasound and intraoperative findings of relevance in terms of tumor aggressiveness that led to the suspicion of the presence of an aggressive variant of papillary cancer. The histopathology of the tall cell variant has a different molecular basis that confers its own morbidity and mortality, being an independent prognostic factor for recurrence. Total thyroidectomy is recommended with prophylactic dissection of the central lymph nodes and eventually lateral neck dissection according to preoperative evaluation followed by postoperative ablation with radioactive iodine.

Isthmusectomy for well-differentiated thyroid carcinoma located to the isthmus: A report of two cases and review of the literature.

Papillary thyroid cancer is the most common endocrine malignancy, and due to its favorable prognosis, the extent of surgery has been a matter of debate. About 10% of these tumors are located in the thyroid isthmus, with no specific management in current guidelines. In the last decades, isthmusectomy has been proposed as a therapeutic option for isthmic papillary thyroid carcinoma, although there is no consensus on its management. We present two cases of patients from our institution with solitary isthmic papillary thyroid carcinoma without clinical macroscopic extrathyroidal extension or clinical-radiological lymph node involvement who were treated with isthmusectomy without prophylactic lymph node dissection. Neither of them had any postoperative complications. Both had an intermediate risk of recurrence due to aggressive variants. None of them had signs of recurrence during follow-up. We intend to show that isthmusectomy seems to be an effective and safe surgical alternative in selected patients through these cases.

El cáncer papilar de tiroides es la neoplasia endocrina más frecuente, y debido a su pronóstico favorable, la extensión de la cirugía ha sido materia de debate. Aproximadamente el 10% de ellos están localizados en el istmo tiroideo, sin un manejo específico según las guías actuales. En las últimas décadas se ha propuesto la istmectomía como alternativa de manejo en el cáncer papilar de tiroides ubicado en el istmo. Presentamos los casos de dos pacientes con cáncer papilar de tiroides ístmico solitario, sin extensión extratiroídea macroscópica clínica ni compromiso ganglionar clínico ni radiológico, que fueron tratados con istmectomía sin disección ganglionar profiláctica. Ninguno tuvo complicaciones postoperatorias. Ambos fueron de riesgo de recurrencia intermedio debido a variantes histológicas agresivas. Ninguno tuvo recurrencia durante el seguimiento. Nuestro objetivo es mostrar que la istmectomía parece ser una alternativa quirúrgica efectiva y segura en pacientes adecuadamente seleccionados.

Intermediate-risk thyroid carcinoma: indicators of a poor prognosis.

OBJECTIVE: The intermediate-risk (IR) category includes tumors with different degrees of aggression. We aimed to identify the risk factors associated with unfavorable response to initial treatment and compare the effect of low/high radioactive iodine (RAI) therapy. METHODS: A total of 614 IR patients were selected from a database, during 1972-2015. All patients underwent total thyroidectomy and RAI therapy and were reclassified after 12-18 months into the favorable (complete/indeterminate) response group and the unfavorable (biochemical/incomplete structural) response group. A total of 92 patients were assessed for late response (mean: 9.19 ± 5.73 years). Age, gender, tumor size, histology, multifocality, vascular invasion, extrathyroidal extension, presence and number of lymph node metastasis, and stimulated thyroglobulin at ablation (sTg) were evaluated. RESULTS: Mean age at diagnosis was 41.47 ± 15.81 years, and 83.6% of the patients were female. Within 12-18 months after initial therapy, unfavorable response was detected in 41.2% of the patients and was associated, in multivariate analysis, with lymph node metastasis (p = 0.041; odds ratio [OR] = 1.9), presence of more than five metastatic lymph nodes (p = 0,017; OR = 2.6), and sTg > 10 ng/mL (p = 0.005; OR = 10.0). For patients with a longer follow-up, sTg >10 ng/mL was associated with unfavorable response (p = 0.002; OR = 6.8). A higher RAI dose was not related to better prognosis at the end of the follow-up. CONCLUSION: A sTg level of >10 ng/mL and lymph node metastasis were associated with an unfavorable response 12-18 months after initial treatment. A RAI dose below 150 mCi was proven sufficient to treat IR patients.

Active surveillance in small cytological indeterminate thyroid nodules: a call to common sense?

PURPOSE: To describe the clinical characteristics and outcomes of patients with cytologically Bethesda IV category (B IV) thyroid nodules who opted for active surveillance. MATERIALS AND METHODS: We prospectively evaluated 155 patients with a single thyroid nodule classified as B IV. Immediate molecular testing and/or thyroid surgery was offered, except when the patient (i) could not afford molecular testing/rejected the surgery, (ii) had a high surgical risk, (iii) had other disorders/comorbidities which needed to be addressed with higher priority, and (iv) had undetectable serum calcitonin levels, in whom active surveillance (AS) was performed. RESULTS: From 155 patients, only two patients could afford molecular testing; 84% (n = 130) underwent immediate thyroid surgery: lobectomy was performed in only 8% (n = 10). AS was the initial management for 15% (n = 23) of the patients. The frequency of tumor enlargement was 14% (n = 3), after a median of 42 months (range, 7-72) of follow-up, without any evidence of lymph node or clinical distant metastases development. Deferred surgery was performed in 4 patients (17%) after a median of 24 months (range, 12-48) of AS. Follicular adenoma was diagnosed in three and a follicular variant of papillary thyroid carcinoma in one patient, all of them without evidence of disease after 12 months of follow-up. CONCLUSIONS: Despite current guidelines does not support AS for indeterminate Bethesda IV nodules, our findings showed that most of these patients had excellent outcomes, in a setting where lobectomy was not the preference and the access to molecular testing was limited. Probably AS could be a valid alternative in these low-risk tumors in selected patients.