Contralateral metastatic papillary thyroid carcinoma and complicated by primary hyperaldosteronism: A case report

Iodine or Not (IoN) for Low-risk Differentiated Thyroid Cancer: The Next UK National Cancer Research Network Randomised Trial following HiLo

To investigate the clinicopathological characteristics of papillary thyroid cancer (PTC) and identify risk factors for postoperative recurrence of PTC with recurrent laryngeal nerve (RLN) involvement. In total, 171 patients (112 women and 59 men, age: 18-80 years, and 65 patients aged ≥ 55) with T4a PTC with RLN involvement, treated at Beijing Tongren Hospital, Capital Medical University, from January 2006 to December 2020, were retrospectively examined. Clinicopathological characteristics, including voice analysis results, and survival outcomes were assessed. The Mann-Whitney U and Kruskal-Wallis H tests were used to analyze differences in acoustic parameters. The Kaplan-Meier method was used to calculate the overall survival (OS) and recurrence-free (RFS) rates. Univariate and multivariate Cox regression analyses were performed of the clinical data. The postoperative follow-up period ranged from 12 to 196 months (mean: 66.18 months). Of the 171 patients, 16 had recurrence and 8 died of thyroid-related diseases. The 5-year OS rate was 95.22%. The 5-year RFS rate was 89.38%. Jitter and shimmer were higher and maximum phonation time was shorter in patients with preoperative vocal cord paralysis (VCP) than in those without RLN involvement, and in those with RLN involvement but without preoperative VCP. Acoustic parameters were similar in patients with no preoperative VCP and those without RLN involvement. Voice analysis results did not differ between cases with RLN adhesion and RLN invasion. Univariate analysis showed that age at onset ≥ 55 years, preoperative RLN palsy, and esophageal invasion were risk factors for postoperative recurrence of PTC with RLN involvement. Multivariate analysis showed that onset age ≥ 55 years (OR 4.52, 95% confidence interval: 1.44-14.19, P = 0.010) was an independent risk factor for recurrence. PTC patients with RLN invasion can achieve good outcomes. Preoperative voice analysis may offer insights into RLN function. Age of onset ≥ 55 years is an independent risk factor for postoperative recurrence in T4a PTC patients.

The new 4th edition World Health Organization classification for thyroid tumors, Asian perspectives.

Recently, the eighth edition of the American Joint Committee on Cancer (AJCC)/tumor node metastasis (TNM) staging system for differentiated thyroid cancer (DTC) was published. Studies evaluating this new edition have so far only comprised patients with papillary thyroid cancer (PTC) or made no distinction between PTC and follicular thyroid cancer (FTC). Therefore, this study evaluated the prognostic value of the eighth edition of the AJCC/TNM staging system in a European population with DTC, focusing on potential differences between PTC and FTC. Adult patients with DTC who were diagnosed and/or treated at a Dutch university hospital between January 2002 and April 2016 were retrospectively studied. Overall survival (OS) and disease-specific survival (DSS) were analyzed for DTC and for PTC and FTC separately according to the seventh and eighth editions using the Kaplan-Meier method. Cox's proportional hazards model was used to compare the effect of PTC and FTC on survival. The statistical model performance was assessed using the C-index, Akaike information criterion (AIC), and the Bayesian information criterion. The study included 792 patients with DTC (79% PTC, 21% FTC) with mean age of 49 years. Median follow-up was 7.2 years. Reclassification using the eighth edition resulted in the downstaging of 282 (36%) patients, an increased number of patients in stages I and II, and an equivalent decrease in patients with stages III and IV. For DTC, as well as for PTC and FTC separately, stage at diagnosis was significantly related to both OS and DSS (p < 0.001). When using the seventh edition, FTC patients had a significantly lower survival rate than PTC patients in stage I and stage IV for OS, and in stage IV for DSS. This difference in survival rates disappeared using the eighth edition. In general, the statistical model performance was better for the eighth than for the seventh edition. In a European population of patients with DTC, the eighth edition of the AJCC/TNM staging system is a better predictor for both OS and DSS than the previous seventh edition for both PTC and FTC. Furthermore, differences in survival rates between PTC and FTC that were present using the seventh edition disappeared using the eighth edition, implying that this new edition is predicting well, regardless of DTC subtype.

Short Call Abstracts

Background: The lung is the most frequent site of distant metastasis from differentiated thyroid cancer (DTC). However, lung metastasis from papillary thyroid cancer (PTC) with persistently negative thyroglobulin (Tg) and elevated Tg antibody (TgAb) levels is an extremely rare entity, and the prognosis is therefore elusive. We investigated the clinical characteristics, long-term outcomes, and prognostic factors of lung metastases in PTC patients with persistently negative thyroglobulin (Tg) and elevated Tg antibody (TgAb) levels during radioactive iodine (131I) treatment and follow-up.Methods: We retrospectively reviewed 10,482 patients with DTC who underwent postoperative 131I treatment from 2007 to 2017 at Shanghai Sixth's People's Hospital. The relationships between progression-free survival (PFS) and several variables were assessed by univariate and multivariate analyses using the Kaplan–Meier method and a Cox proportional hazards model, respectively.Results: Forty-seven patients with PTC were enrolled in this study (4.48‰ of all patients with DTC). The median age at the initial diagnosis of lung metastasis was 39.6 ± 15.4 years, and the patients comprised 14 male and 33 female patients (male: female ratio = 1.00:2.36). Twenty-five patients had 131I avidity and 22 had non-131I avidity. At the end of the 5-years follow-up, 12 patients exhibited progressive disease (PD), and 2 patients had died. At the end of the 10-years follow-up, 21 patients showed PD and five patients had died. The 5- and 10-year PFS rates were 74.47 and 53.32%, respectively; the 5- and 10-years overall survival (OS) rates were 95.74 and 89.36%, respectively. The timing of diagnosis of lung metastases, maximal size of lung metastases, and 131I avidity were significantly associated with the 5-years PFS rate (P = 0.035, P = 0.030, and P<0.001, respectively). Only 131I avidity was associated with the 10-years PFS rate (P < 0.001). The multivariate analyses also showed that non-131I avidity were the independent poor prognostic factors for 10-years PFS at the end of follow-up (P < 0.001).Conclusions: Lung metastases from PTC in patients with persistently negative Tg and elevated TgAb levels had an excellent prognosis and survival rate during 131I treatment and follow-up. The loss of 131I avidity remained the strongest independent predictor of a poor prognosis and survival in these patients.

The goal was to determine if there was a relation between the introduction of evidence-based radioactive iodine (RAI) treatment guidelines for differentiated thyroid cancer (DTC) at Cedars-Sinai Medical Center (CSMC) and subsequent RAI use. In addition, we compared RAI treatment rates for DTC at CSMC to data from the National Cancer Database (NCDB) to see if the trends in RAI use at CSMC differed from the national trends. RAI data from the CSMC Thyroid Cancer Center were reviewed to determine if RAI treatment was given appropriately. Kaplan-Meier curves were used to estimate disease-free survival for patients who received or did not receive treatment. RAI data from the NCDB were also used to compare how CSMC treatment rates compare nationally. There were 444 CSMC patients identified with DTC between 2009 and 2012. Approximately 95% of the patients had papillary thyroid cancer (n=423) with 65% in the stage I risk group (n=290). Kaplan-Meier curves for stages I-III show that those who did not receive RAI treatment had 100% disease-free survival, which was better than those who had received RAI. However, given that the total population in both stages II and III is quite small, having received RAI ablation was not found to be statistically significant. Stage I patients who received RAI had a significantly increased incidence of recurrent disease. The NCDB RAI rates for all DTC stages in each year have consistently been over 50% with an overall treatment rate of 57%. There were significant differences in the treatment rates between CSMC and NCDB, with a decrease in the use of RAI in low-risk patients with stage I tumors at CSMC following institution of the guidelines. Prudent use of RAI treatment should be considered for low-risk patients. Ablation rates have been decreasing steadily at CSMC, particularly among low-risk patients, with the adoption of more stringent RAI treatment guidelines. It is apparent from our data that physician practices can change with the implementation and dissemination of evidence-based guidelines for the treatment of DTC with RAI.

Disclosure: A.W. Maciel: None. T. Freitas: None. D.L. Danilovic: None. G.F. Fagundes: None. F. Freitas-Castro: None. L. Santana: None. A. Guimaraes: None. A. Pio-Abreu: None. J. V. Silveira: None. F. Consolim-Colombo: None. L. Bortolotto: None. M.C. Fragoso: None. A. Latronico: None. L. Drager: None. B.B. Mendonca: None. A.O. Hoff: None. M.Q. Almeida: None. Introduction: Aldosterone excess can cause oxidative stress leading to DNA damage in vitro and in vivo. Single case reports demonstrated a coincidence of primary aldosteronism (PA) with different malignancies. A higher prevalence of thyroid nodules and non-toxic multinodular goiter was described in patients with PA compared to those with essential hypertension (HT). A single study showed an association between PA and papillary thyroid cancer (PTC), but without a paired control group. Objective: To assess PA prevalence in a transversal cohort of patients with PTC and HT compared to a paired control group with HT. Methods: In this cross-sectional case-control study, PA was investigated in all patients with PTC and HT (n= 114), regardless of HT severity, under active surveillance at a cancer institute from 2019 to 2022. The control group included 228 (2:1) age-, sex- and body mass index (BMI)-matched individuals from a retrospective cohort of HT previously investigated for PA from 2011 to 2022. Serum aldosterone and plasma direct renin concentrations were measured by a chemiluminescent immunoassay. A positive PA screening was defined by aldosterone ≥10 ng/dL and aldosterone to renin ratio ≥2 ng/dL/μUI/mL. Results: Age, sex and BMI were not statistically different between PTC and control groups, respectively (age 59.8 ± 12 vs. 58.9 ± 12.3 yrs, p= 0.67; 79% vs. 81% women, p= 0.67; BMI 30.7 ± 5.8 vs. 30.8 ± 6.5 Kg/m2, p= 0.98). PA was diagnosed in 35 out of 114 PTC patients with HT. The prevalence of PA in the PTC group (30.5%, confidence interval (IC) 22.6%-40.1%) was significantly higher when compared to the paired control group with HT (11.84%, CI 8.08%-16.93%; p&amp;lt; 0.0001). Although PA prevalence was higher in the PTC group, only 20.2% had stage 3/resistant HT (vs. 38% in the control group, p= 0.003). The number of anti-hypertensive medications was lower in the PTC group compared to controls (2 drugs, 1 to 3 vs. 4 drugs, 3 to 5, respectively; p&amp;lt; 0.001). When analyzing only PA patients in both groups, frequency of stage 3/resistant HT and number of medications were lower in the PTC group (p&amp;lt; 0.001 and p&amp;lt; 0.001, respectively). Although HT was more severe in PA patients without PTC, aldosterone and renin levels were not different in PA patients from PTC and control groups, respectively (p= 0.15 and p= 0.34). Conclusion: PA prevalence was strikingly high among patients with PTC and HT, supporting the recommendation of PA screening in this patient group, regardless of HT severity. Presentation: Thursday, June 15, 2023

ObjectiveDifferentiated thyroid carcinomas (DTCs) are classified into papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). DTCs are analyzed as a single group in clinical studies that investigated the prognostic factors and prognosis of these malignancies. However, the biological behaviors of these carcinomas significantly differ. In the present study, we aimed to detect differences in the outcomes between PTC and FTC in Mansoura University Hospital in Egypt.MethodsA total of 558 patients with histologically proven thyroid carcinomas from January 2003 to December 2012 were retrospectively enrolled. The clinical and pathological data of patients were reviewed.ResultsLarge primary tumor size, lymph node involvement, extrathyroid extension, and distant metastasis were significant poor prognostic factors for overall survival (OS) in old PTC patients. Cox hazard analysis showed that the patient’s age, extra thyroid extension, and distant metastasis were the only independent prognostic factors. In FTC patients, only the distant metastasis and degree of tumor invasion were significant poor prognostic factors in OS univariate analysis. However, these factors were nonsignificant in multivariate analysis. The 10-year OS rates were 97% and 89% for PTC and FTC, respectively (P=0.003). The 10-year disease-free survival (DFS) rates were 77.2% in PTC vs. 65% in FTC (P=0.179).ConclusionThe significant prognostic factors vary between the two types of DTCs. Therefore, PTC and FTC patients need to be analyzed and reported independently. PTC survival is widely and significantly affected by age, extrathyroid extension, and distant metastasis. By contrast, these factors were nonsignificant in FTC, which showed poorer survival than PTC.

Background Thyroid cancer is the most common endocrine malignancy, with a recent global increase of 20% in age-related incidence. Ultrasonography and ultrasonography-guided fine-needle aspiration biopsy (FNAB) are the most widely used diagnostic tests for thyroid nodules; however, it is estimated that up to 25% of thyroid biopsies are cytologically inconclusive. Molecular markers can help guide patient-oriented and targeted treatment of thyroid nodules and thyroid cancer. Methods Datasets related to papillary thyroid cancer (PTC) or thyroid carcinoma (GSE129562, GSE3678, GSE54958, GSE138042, and GSE124653) were downloaded from the GEO database and analysed using the Limma package of R software. For functional enrichment analysis, the Kyoto Encyclopedia of Genes and Genomes pathway analysis and Gene Ontology were applied to differentially expressed genes (DEGs) using the Metascape website. A protein-protein interaction (PPI) network was built from the STRING database. Gene expression, protein expression, immunohistochemistry, and potential functional gene survival were analysed using the GEPIA website, the Human Protein Atlas website, and the UALCAN website. Potential target miRNAs were predicted using the miRDB and Starbase datasets. Results We found 219 upregulated and 310 downregulated DEGs, with a cut-off of p < 0.01 and ∣log FC | >1.5. The DEGs in papillary thyroid cancer were mainly enriched in extracellular structural organisation. At the intersection of the PPI network and Metascape MCODEs, the hub genes in common were identified as FN1, APOE, CLU, and SDC2. In the targeted regulation network of miRNA-mRNA, the hsa-miR-424-5p was found to synchronously modulate two hub genes. Survival analysis showed that patients with high expression of CLU and APOE had better prognosis. ConclusionsCLU and APOE are involved in the molecular mechanism of papillary thyroid cancer. The hsa-miR-424-5p might have the potential to reverse the processes of papillary thyroid cancer by modulating the hub genes. These are potential targets for the treatment of patients with papillary thyroid cancer.

To evaluate treatment outcomes following radioactive iodine (RAI) treatment with a cumulative dose of ≥≥600 mCi in differentiated thyroid carcinoma (DTC) patients, a retrospective review of medical records was done in 176 DTC patients with a cumulative dose of ≥600 mCi from January 1993 to December 2013. All patients were followed up for at least 2 years after receiving 600 mCi of I-131 treatment. Remission criteria were no clinical and imaging evidence of disease and low serum thyroglobulin levels during thyroid-stimulating hormone suppression of <0.2 ng/ml or of <1 ng/ml after stimulation in the absence of interfering antibodies. A total of 176 patients were included in the study: 137 – papillary thyroid cancer, 29 – follicular thyroid cancer, 9 – mixed papillary and follicular thyroid cancer, and 1 – Hurthle cell carcinoma. Most of the patients (118, 67%) had locoregional metastasis, whereas 48 patients (27%) had distant metastases at presentation. The median cumulative dose was 900 mCi (range: 600–2200 mCi). The mean follow-up period was 82.84 ± 42.41 months. Only 16 patients (9.1%) met remission criteria at the end of treatment. The rest of patients (160, 90.9%) were not remitted: stable disease in 94 (53.4%), at least 1 metastasis without I-131 uptake in 34 (19.3%), progressive disease in 21 (11.9%), and death during the whole follow-up period in 11 (6.3%). Two patients (1.1%) developed second primary malignancy. Eighteen cases were suspected of bone marrow suppression (14 cases [7.9%] had anemia and 5 cases [2.8%] had neutropenia). Seven patients (3.9%) developed permanent salivary gland dysfunction. Although the complications after receiving RAI treatment with a cumulative dose of ≥≥600 mCi were low and not severe, the patients with remission were in <10%. Our study suggests that the decision to administer further treatments should be made on an individual basis because beneficial effects may be controversial.

For patients with differentiated thyroid cancer (DTC), that is, papillary thyroid cancer (PTC) and follicular thyroid cancer (FTC), the American Thyroid Association and European Thyroid Association generally recommend radioactive iodine (RAI) therapy after surgery only for high-risk patients. For intermediate-risk patients, RAI therapy is recommended only as a should-be-considered option. For low-risk patients, RAI therapy is not routinely recommended. Other countries, such as Germany, are more in favor of using RAI. Thus, RAI therapy remains a matter of controversial debate, because prospective long-term data on survival are scarce. Methods: We retrospectively compared long-term relative survival in DTC cohorts treated with and without RAI. From the Surveillance, Epidemiology, and End Results Program database, 101,087 patients harboring DTC were identified between 2000 and 2020. Patient cohorts were subdivided based on histology (classical PTC, aggressive variants of PTC, FTC, and minimally invasive FTC). These cohorts were stratified into the following categories: very low risk, low risk, intermediate risk, and high risk. Relative survival was determined for each subgroup. Statistics included a z-test specifically developed for comparison of relative survival, testing the long-term effect of RAI therapy (3, 5, and 10 y). Results: The relative survival rate is higher or tends to be higher in most subgroups undergoing RAI therapy than in subgroups not undergoing RAI therapy. Even for low-risk minimally invasive FTC, the 10-y relative survival rate tends to be higher by 2.0% (P = 0.055). For larger tumor size or lymph node involvement in classical PTC, a 10-y relative survival benefit of 1.3%-2.0% (P = 0.045) in the RAI subgroup prevails. In high-risk DTC, benefits in relative survival of up to 30.9% (P < 0.05) were observed. Relative survival is not negatively affected in any RAI subgroup. Conclusion: In patients with DTC, depending on histology subtype, a benefit in relative survival prevails in low-, intermediate-, and high-risk subgroups that underwent RAI therapy compared with patients who did not undergo RAI therapy. Even in low-risk minimally invasive FTC, a clear trend toward higher survival rates is observed. For PTC, a survival benefit prevails in the presence of lymph node involvement, larger tumor size, or distant metastasis.

The presentation and outcome of differentiated thyroid carcinoma (DTC) in developing countries are different from the developed nations. We report the clinicopathologic profile and long-term outcome of DTC in an iodine-deficient area (IDA) in a developing country. This retrospective study included 302 patients with DTC operated between 1989 and 2002. These patients had been followed up for a minimum period of 5 years after surgery. Clinicopathological profile, intervention, and follow-up details were noted. Mean age of the patients was 42 +/- 14 years. Mean follow-up period was 80 +/- 34 (24-196) months. Papillary thyroid carcinoma (PTC), follicular thyroid carcinoma (FTC), and poorly differentiated thyroid carcinoma (PDTC) was present in 62, 30, and 8% patients, respectively. Mean tumor size was 3.5 cm. Tumor multicentricity was noted in 40% of PTC, 22.2% of FTC, and 25% of PDTC patients. Lymphadenopathy was observed in 45, 10, and 67% patients with PTC, FTC, and PDTC, respectively. Extrathyroidal invasion and distant metastasis were observed in 36.8% (PTC 33%; FTC 36%; PDTC 71%) and 27% (PTC 17%; FTC 44%; PDTC 42%) of cases, respectively. Twenty percent of patients had synchronous metastases. Risk stratification ratio was 1:1.8 (high-risk vs. low-risk). Initial operative procedure was total thyroidectomy in 86.5% cases, and therapeutic lymph node dissection was performed in 37% cases. A total of 77.2% patients received adjuvant radioiodine therapy. Disease recurred in 26.6% of patients (thyroid bed recurrence 1.7%), and 21.2% patients died during follow-up. Overall survival (OS) rate at 10 years in both low-risk and high-risk groups of FTC (80 and 54%) was inferior to PTC (94 and 62%). Five-year OS for PDTC was 50%. Tumor multicentricity was a significant risk factor for OS in the low-risk group, whereas the presence of skeletal metastases and extrathyroidal invasion were significant factors for OS in the high-risk group. Advance stage at presentation and proportionately high rates of FTC and PDTC contribute to poor outcome of DTC in developing countries. Despite dismal outcome, total thyroidectomy seems to prevent thyroid bed recurrence in surviving patients.

Thyroid cancer, especially papillary carcinoma, metastasizes most often into cervical lymph nodes. Cervical ultrasound and ultrasound-guided fine-needle aspiration biopsy are the most sensitive modalities in detecting locoregional neck recurrence. The aim of this study was to illustrate the ultrasound spectrum of lymph node metastases from papillary thyroid carcinoma. During 1998-2002 years due to suspicion of recurrence of thyroid cancer, 75 ultrasound-guided fine-needle aspiration biopsies of regional lymph nodes were performed. Ultrasound examination of 75 patients with thyroid cancer (56 women and 19 men; mean age of patients was 54.67+/-12.89 years) was performed. All biopsies were performed on nonpalpable lesions (lymph node short axis < or =1.5 cm). A total of 75 ultrasound-guided fine-needle aspiration biopsies of regional lymph nodes under suspicion of malignancy were performed. Only 5 (6.7%) of the 75 lymph nodes were cystic with internal septation. Other 70 (93.3%) lymph nodes were solid. Cytopathological results of 75 ultrasound-guided fine-needle aspiration biopsies from regional cervical lymph nodes were noninformative in 4 (5.3%) cases, benign - 40 (53.4%), suspicion - 4 (5.3%), and malignant - 27 (36.0%) cases. Eighteen patients underwent surgery for regional lymph nodes. All cystic metastases were confirmed to be papillary thyroid carcinoma on pathologic examination. Ultrasound cannot exactly distinguish benign from malign lesions, but sonographic appearance can suggest malignancy and help in selection of the correct lymph nodes to aspirate with ultrasound-guided fine-needle aspiration biopsy. Cystic lymph node metastases may occur in papillary thyroid carcinoma. Cystic neck lesion patients with thyroid papillary carcinoma should always be verified with fine-needle aspiration biopsy.

We read with interest the article ‘‘Prognostic value of oncoprotein expressions in thyroid papillary carcinoma’’ by A. Z. Balta, A. I. Filiz, Y. Kurt, I. Sucullu, E. Yucel and M. L. Akin [1] because our most recent studies of p53 protein have also been showing that immunohistochemical (IHC) staining is augmented in patients with papillary thyroid carcinoma (PTC). However, we found some different associations that deserve further reflection, especially in what concerns clinical pathological aspects of PTC. We analyzed a large series of cases: 206 patients with differentiated thyroid cancer (DTC), including 164 PTC (106 classic form; 54 follicular variant; and 04 tall cell variant) and 42 follicular carcinomas, using monoclonal mouse anti-human p53 antibody (clone DO-7; monoclonal, DAKO, Carpenteria, CA, USA). In addition, we studied 105 benign thyroid tissues including: 50 nodular goiters, 55 follicular adenomas and 18 normal thyroid tissues. Our patients were all managed according to a standard protocol and followed up for 53.8 ± 41.0 months. Although our quantitative analysis using the automated cellular imaging system (ACIS-III) (Chroma Vision Medical Systems, Inc, DAKO) identified mean values of 5.11 % and medians of 1.71 % of p53 nuclei expression, we concur with Balta et al. interpretation and considered all the benign cases negative. Conversely, 28.67 % of our malignant tissues expressed p53 with a mean of 41.26 % and a median of 28.67 % stained nuclei. Balta et al. observed that p53 expression was significantly associated with the presence of lymph node metastasis and extrathyroidal invasion (p = 0.003 and p = 0.004, respectively). In contrast, we found higher expression of p53 in patients presenting better prognostic features, such as: females (p = 0.0367); smaller (\2 cm) and solitary tumors (p = 0.0105) that did not present extrathyroidal invasion (p = 0.0241). P53 was also more expressed in patients evolving free of disease than in patients with persistence or recurrence (p = 0.0310). A proportional hazard regression analysis (Cox’s multivariate proportional hazard model) identified age (p = 0.0070; HR = 1.0675; CI 95 %, 1.0180–1.1195) and the presence of metastasis at diagnosis (p = 0.0384; HR = 4.6889; CI 95 %, 1.0862–20.2417) as independent variables that influence relapse-free survival, excluding any role of p53. In addition, the Kaplan–Meier survival curve did not identify p53 as a factor affecting recurrence-free survival. The differences between our findings and those by Balta et al. [2] could be related to the patients investigated, since they have selected a group that does not correspond to the usual profile of DTC patients seen in clinical practice. In fact, they described a study population of 53 men and 34 women, whereas it is well known that 70–80 % of the DTC patients are females. Male patients are usually diagnosed in more advanced stages and may present more aggressive features and a worse outcome than females. In addition, Balta et al. classified 42 out of their 47 PTC patients as high-risk patients and only 5 as low-risk patients. Our study population (80.4 % women and 19.6 % men), with a large majority of low-risk patients (129 out of 206 DTC cases— 62.6 % were pTNM stages I and II), is more representative of the DTC usual patients. Although our results contrast with the ones described by Balta et al., they evidence the importance of clinical and M. A. Marcello (&) E. C. Morari L. S. Ward University of Campinas (FCM-Unicamp), Campinas, Sao Paulo, Brazil e-mail: marjoryam@gmail.com