Management Of Differentiated Thyroid Cancer Research Articles

12382 A Prospective Analysis of De Novo Thyroglobulin Antibodies in Patients with Differentiated Thyroid Cancer Using the Italian Thyroid Cancer Observatory Repository

Abstract Disclosure: B.S. Neutel: None. G. Grani: None. S. D'elia: None. C. Durante: None. A.G. Gianoukakis: None. The prevalence and significance of newly developed (de novo) thyroglobulin antibodies (dnTgAb) in patients with differentiated thyroid cancer (DTC) who were initially thyroglobulin antibody (TgAb) negative, is not well established. We sought to examine the phenomenon of dnTgAb using the Italian Thyroid Cancer Observatory (ITCO) database. Beginning in 2013, the ITCO repository prospectively collected clinical data on DTC management in a consecutive series of newly diagnosed patients treated in large academic centers distributed across Italy. Patients were managed by treating physicians based on perceived best practice. Pre-specified parameters were collected. Clinical status, investigations, and treatments were updated periodically. We formulated inclusion and exclusion criteria to mirror previously published literature studying dnTgAb. Patients included in the analysis were initially TgAb negative at their first postoperative check and had no evidence of persistent disease at their 1 year follow up visit. The dnTgAb group included patients who were initially TgAb negative and then developed TgAb on at least one measurement from the second postoperative check or later. All patients included in the study had at least 3 years of follow up and 3 TgAb measurements. At the time of analysis, 5360 patients were without persistent disease at 1 year. 2107 of these patients had a least 3 years of follow up and 3 TgAb measurements. 334 patients with positive TgAb at their first lab check and an additional 124 patient with incomplete data were excluded. 1649 patients met criteria for inclusion. Median follow up time was 1.85 years. DnTgAb occurred in 4.3% of patients (n=71). We found no statically significant difference in gender, tumor size, tumor focality, extrathyroidal extension, AJCC stage and ATA risk level between the persistently negative TgAb group and the dnTgAb group. Only primary tumor vascular invasion occurred at a higher rate in patients within the dnTgAb group when compared to the persistently negative group (p=0.012). Structural DTC recurrences occurred in 1.4% (n=22) of persistently TgAb negative patients and 5.6% (n=4) of patients with dnTgAb (p=0.02).This is the largest and first prospective cohort used to evaluate the prevalence and clinical significance of dnTgAb. DnTgAb occurred at a clinically relevant rate and there was a statistically significant relationship between detection of dnTgAb and structural DTC recurrence. The study is limited by the small overall recurrence rates and the exclusion of patients with less than 3 years of follow up. Presentation: 6/3/2024

Prevalence and Analysis of Risk Factors for RAI-Refractory Thyroid Cancer Patients: A 5-Year Retrospective Analysis from a Single Institution in Indonesia

Background: Radioactive iodine (RAI) therapy is a cornerstone in the management of differentiated thyroid cancer (DTC). However, a subset of patients develops RAI-refractory disease, characterized by the inability to concentrate radioiodine, leading to limited treatment options and a poorer prognosis. This study aimed to investigate the prevalence and identify potential risk factors associated with RAI-refractory DTC in an Indonesian population. Methods: A retrospective analysis was conducted on patients diagnosed with DTC and treated with RAI at a single tertiary care center in Indonesia between 2019 and 2023. Data on demographics, clinical characteristics, tumor features, and treatment outcomes were collected. RAI-refractoriness was defined as the absence of iodine uptake on diagnostic whole-body scans after cumulative RAI activity of 600 mCi or more. Bivariate and multivariate analyses were performed to identify risk factors for RAI-refractoriness. Results: A total of 194 patients with DTC were included in the study. The prevalence of RAI-refractoriness was 90%. The median age at diagnosis was 55 years (range 18-82), and 72% were female. Papillary thyroid carcinoma was the most common histological subtype (92%). In bivariate analysis, older age at diagnosis (p=0.02), male gender (p=0.04), and the presence of distant metastases at diagnosis (p<0.001) were significantly associated with RAI-refractoriness. In multivariate analysis, only the presence of distant metastases remained an independent predictor of RAI-refractoriness (odds ratio 3.8, 95% confidence interval 1.5-9.2, p=0.003). Conclusion: RAI-refractoriness is a significant clinical challenge in the management of DTC, with a high prevalence observed in this Indonesian cohort. The presence of distant metastases at diagnosis emerged as a strong predictor of RAI-refractoriness. Further research is needed to elucidate the underlying mechanisms of RAI-refractoriness and develop novel therapeutic strategies for this patient population.

Current Advances in Radioactive Iodine-Refractory Differentiated Thyroid Cancer.

Differentiated thyroid cancer (DTC) patients have an outstanding overall long-term survival rate, and certain subsets of DTC patients have a very high likelihood of disease recurrence. Radioactive iodine (RAI) therapy is a cornerstone in DTC management, but cancer cells can eventually develop resistance to RAI. Radioactive iodine-refractory DTC (RAIR-DTC) is a condition defined by ATA 2015 guidelines when DTC cannot concentrate RAI ab initio or loses RAI uptake ability after the initial therapy. The RAIR condition implies that RAI cannot reveal new met-astatic foci, so RAIR-DTC metabolic imaging needs new tracers. 18F-FDG PET/CT has been widely used and has demonstrated prognostic value, but 18F-FDG DTC avidity may remain low. Fibroblast activation protein inhibitors (FA-Pi)s, prostatic-specific membrane antigen (PSMA), and somatostatin receptor (SSTR) tracers have been proposed as theragnostic agents in experimental settings and Arg-Gly-Asp (RGD) peptides in the diagnostic trial field. Multi-targeted tyrosine kinase inhibitors are relatively new drugs approved in RAIR-DTC therapy. Despite the promising targeted setting, they relate to frequent adverse-event onset. Sorafenib and trametinib have been included in re-differentiation protocols aimed at re-inducing RAI accumulation in DTC cells. Results appear promising, but not excellent. RAIR-DTC remains a challenging nosological entity. There are still controversies on RAIR-DTC definition and post-RAI therapy evaluation, with post-therapy whole-body scan (PT-WBS) the only validated criterion of response. The recent introduction of multiple diagnostic and therapeutic agents obliges physicians to pursue a multidisciplinary approach aiming to correct drug introduction and timing choice.

Current approach to pediatric differentiated thyroid cancer.

Differentiated thyroid cancers (DTC) is a rare cancer in children and adolescents, having features of different clinical presentation, biological behavior, and treatment from adult population. Most of the patient management guidelines are based on literature on adult population and the literature on children and adolescents still limited. There are still unsettled issues regarding both patient management and the therapy. However, the current approach for treatment of DTC includes thyroidectomy, lymph node dissection in patients with nodal metastases and possible use of Iodine-131 radiotherapy. The incidence of DTC is low in pediatric population, and the characteristics of the disease vary among different age groups within this population. Therefore, the literature depends on small cohorts and heterogeneous retrospective studies. This paper aims to review the current literature and give an overview to the approach in the management of DTC in pediatric population. DTC in pediatric population, has an aggressive nature, however the patient's overall survival is excellent. A multidisciplinary approach in the management of pediatric DTC patients would yield fewer side effects and a better life quality.

The effect of COVID-19 pandemic restrictions on the management of differentiated thyroid cancer in Turkey: a single tertiary centre experience.

Many countries have implemented unprecedented health measures since the World Health Organisation declared the novel coronavirus disease 2019 (COVID-19) a global pandemic. These measures have resulted in delays in the diagnosis of differentiated thyroid cancer (DTC). However, there is limited data on the impact of restrictions imposed during the pandemic on DTC management. Thus, the aim of this study is to analyse the clinicopathological and follow-up data of DTC patients diagnosed before and during the COVID-19 outbreak. This retrospective study included 191 DTC patients that were diagnosed between December 2018 and June 2021. The patients were divided into two groups: patients diagnosed before (December 2018 to February 2020) and during (March 2020 to June 2021) the COVID-19 pandemic. The clinicopathological and follow-up data between the two groups were compared. Similar preoperative cytology results were obtained from the two groups. No difference with regard to tumour size, lymphovascular invasion and extrathyroidal invasion was observed between the two groups. While the American Thyroid Association risk stratification was similar between the two groups, radioactive iodine (RAI) therapy was applied less during the COVID-19 period. Although RAI therapy was administered at a lower rate during the COVID-19 period, the recurrence rates among patients after two years of follow-up were similar to those during the pre-COVID-19 period. Although the COVID-19 pandemic restrictions during the pandemic period caused difficulties in the management of DTC patients, this did not negatively affect their prognosis. These findings can confirm the applicability of active surveillance in DTC patients and may help change the real-life treatment practices in selected low-risk DTC patients.

A hybrid machine learning model combining association rule mining and classification algorithms to predict differentiated thyroid cancer recurrence.

Differentiated thyroid cancer (DTC) is the most prevalent endocrine malignancy with a recurrence rate of about 20%, necessitating better predictive methods for patient management. This study aims to create a relational classification model to predict DTC recurrence by integrating clinical, pathological, and follow-up data. The balanced dataset comprises 550 DTC samples collected over 15 years, featuring 13 clinicopathological variables. To address the class imbalance in recurrence status, the Synthetic Minority Over-sampling Technique for Nominal and Continuous (SMOTE-NC) was utilized. A hybrid model combining classification algorithms with association rule mining was developed. Two relational classification approaches, regularized class association rules (RCAR) and classification based on association rules (CBAR), were implemented. Binomial logistic regression analyzed independent predictors of recurrence. Model performance was assessed through accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and F1 score. The RCAR model demonstrated superior performance over the CBAR model, achieving accuracy, sensitivity, and F1 score of 96.7%, 93.1%, and 96.7%, respectively. Association rules highlighted that papillary pathology with an incomplete response strongly predicted recurrence. The combination of incomplete response and lymphadenopathy was also a significant predictor. Conversely, the absence of adenopathy and complete response to treatment were linked to freedom from recurrence. Incomplete structural response was identified as a critical predictor of recurrence risk, even with other low-recurrence conditions. This study introduces a robust and interpretable predictive model that enhances personalized medicine in thyroid cancer care. The model effectively identifies high-risk individuals, allowing for tailored follow-up strategies that could improve patient outcomes and optimize resource allocation in DTC management.

Differentiated thyroid cancer: a focus on post-operative thyroid hormone replacement and thyrotropin suppression therapy.

This review focuses on post-operative thyroid hormone replacement and thyrotropin suppression therapy in patients with differentiated thyroid cancer. A clinical review. Differentiated thyroid cancers (DTC), including papillary and follicular thyroid cancers, have an excellent prognosis and their management leverages a unique set of clinical tools arising from homology to the normal thyroid follicular cell. Surgery is the cornerstone of initial management, and post-operative care often requires thyroid hormone replacement therapy, which may be approached with the intent of physiologic normalization or used pharmacologically to suppress TSH as part of a DTC treatment. Management of DTC and approaches to TSH suppression are tailored to an individual's risk of DTC recurrence and are adjusted to a patient's clinical status and comorbidities over time with the goal of mitigating risk and maximizing benefit.

Advances in transcriptomics and proteomics in differentiated thyroid cancer: An updated perspective (Review).

Thyroid cancer (TC) is a broad classification of neoplasms that includes differentiated thyroid cancer (DTC) as a common histological subtype. DTC is characterized by an increased mortality rate in advanced stages, which contributes to the overall high mortality rate of DTC. This progression is mainly attributed to alterations in molecular driver genes, resulting in changes in phenotypes such as invasion, metastasis and dedifferentiation. Clinical management of DTC is challenging due to insufficient diagnostic and therapeutic options. The advent of-omics technology has presented a promising avenue for the diagnosis and treatment of DTC. Identifying molecular markers that can predict the early progression of DTC to a late adverse outcome is essential for precise diagnosis and treatment. The present review aimed to enhance our understanding of DTC by integrating big data with biological systems through-omics technology, specifically transcriptomics and proteomics, which can shed light on the molecular mechanisms underlying carcinogenesis.

Integrated metabolic and genetic analysis reveals distinct features of human differentiated thyroid cancer.

Differentiated thyroid cancer (DTC) affects thousands of lives worldwide each year. Typically, DTC is a treatable disease with a good prognosis. Yet, some patients are subjected to partial or total thyroidectomy and radioiodine therapy to prevent local disease recurrence and metastasis. Unfortunately, thyroidectomy and/or radioiodine therapy often worsen(s) quality of life and might be unnecessary in indolent DTC cases. On the other hand, the lack of biomarkers indicating a potential metastatic thyroid cancer imposes an additional challenge to managing and treating patients with this disease. The presented clinical setting highlights the unmet need for a precise molecular diagnosis of DTC and potential metastatic disease, which should dictate appropriate therapy. In this article, we present a differential multi-omics model approach, including metabolomics, genomics, and bioinformatic models, to distinguish normal glands from thyroid tumours. Additionally, we are proposing biomarkers that could indicate potential metastatic diseases in papillary thyroid cancer (PTC), a sub-class of DTC. Normal and tumour thyroid tissue from DTC patients had a distinct yet well-defined metabolic profile with high levels of anabolic metabolites and/or other metabolites associated with the energy maintenance of tumour cells. The consistency of the DTC metabolic profile allowed us to build a bioinformatic classification model capable of clearly distinguishing normal from tumor thyroid tissues, which might help diagnose thyroid cancer. Moreover, based on PTC patient samples, our data suggest that elevated nuclear and mitochondrial DNA mutational burden, intra-tumour heterogeneity, shortened telomere length, and altered metabolic profile reflect the potential for metastatic disease. Altogether, this work indicates that a differential and integrated multi-omics approach might improve DTC management, perhaps preventing unnecessary thyroid gland removal and/or radioiodine therapy. Well-designed, prospective translational clinical trials will ultimately show the value of this integrated multi-omics approach and early diagnosis of DTC and potential metastatic PTC.

A tribute to Ernest L. Mazzaferri, MD and the lasting impact that he had on thyroid cancer care ten years after his death.

This viewpoint highlights the contributions of Dr. Ernest Mazzaferri, a prominent figure in the field of thyroid cancer care, who made significant contributions to the diagnosis and treatment of this disease. Dr. Mazzaferri's first paper on thyroid cancer, published in 1977, established fundamental principles that remain fundamental to differentiated thyroid cancer management. He was an advocate of total thyroidectomy and of postoperative radioiodine therapy and contributed to improving thyroid fine needle aspiration techniques. Dr. Mazzaferri's leadership in developing guidelines for the management of thyroid cancer and thyroid nodules has been influential and widely accepted. His groundbreaking work established a systematic and data-driven approach to the diagnosis and treatment of thyroid cancer that continues to shape the field of thyroid cancer care today. This Viewpoint reflects on his lasting impact ten years after his death.

ODP532 Fractionated Radioactive Iodine Therapy in Management of Differentiated Thyroid Cancer

Abstract Introduction Management of differentiated thyroid cancer (DTC) requires individualized treatment plans that are tailored to the risk of disease recurrence. Radioactive iodine treatment (RIT) remains a treatment modality that is valuable in certain patients with DTC. The lack of institutional availability and travel bans imposed by the COVID-19 pandemic did not allow a subset of our patients to get intermediate or high-dose RIT. As an alternative, fractionated low-dose RITs given over a short time interval have been used. We aim to study the response to therapy in this patient population. Materials and methods This retrospective study was performed at a tertiary care hospital in Qatar. Between 2015-2020, patients who completed at least 2 doses of low-dose RIT within 6-12 months with at least one staging visit 3-6 months after their last treatment were included in the study. Results 69 patients met our inclusion criteria, 30 (43.5%) of whom were males and 39 (56.5%) females. The mean age at diagnosis was 40.7 +/- 9.35 years. Classic papillary thyroid cancer was the predominant histological variant (76.6%). Based on surgical pathology, the initial risk of disease recurrence was high in 24 (34.8%) patients, intermediate in 21 (30.4%) patients, and low in 21 (30.4%) patients. 3 (4.3%) patients did not have complete data for classification. Lymphatic invasion was noted in 16 (23.2%), vascular invasion in 15 (21.7%), positive margins in 30 (43.5%) and extra-nodal invasion in 10 (14.5%) patients. Patients underwent between 2-6 fractionated RITs, with the majority having undergone 2. In the low-risk group, 9 (42.9%) patients had an excellent response to therapy at last follow-up, 3 (14.3%) had the persistent structural disease, and 9 (42.8%) patients had an indeterminate response. In the intermediate-risk group, 7 (33.4%) patients had excellent response, 2 (9.5%) had the biochemically persistent disease, 8 (38.1%) had the structurally persistent disease, and 4 (19%) had an indeterminate response. In the high-risk group, 5 (20.8%) patients had excellent response, 13 (54.2%) had a structurally persistent disease, and 6 (25%) patients had an indeterminate response to therapy. Conclusion A similar response to therapy has been reported in the literature in the low and high-risk recurrence groups, suggesting that additional RIT may not be beneficial. In the intermediate risk of recurrence group, there is a higher percentage of patients with structural evidence of disease compared to what is reported in the literature, suggesting that perhaps a single intermediate or high dose RIT may be more beneficial. Either way, the c urrent management of DTC should be based on dynamic risk assessment to guide the need for further therapies. Presentation: No date and time listed

Prophylactic central neck dissection in differentiated thyroid cancer: risks and benefits in a population with a high rate of tumour recurrence.

The role of prophylactic central neck dissection (pCND) in differentiated thyroid cancer (DTC) is still controversial. In a cohort of 274 DTC cN0 patients with a high rate of tumour recurrence, who underwent total thyroidectomy with or without pCND, clinical and histopathological features were retrospectively analysed. In our cohort, no clinical or histopathological features are able to predict the presence of central lymph node metastases (CLNM) at diagnosis, which instead represents the only variable significantly associated with a higher risk of long-term tumour relapse, independently from age, sex, BMI and radioiodine treatment (OR=1.03, CI95% 1.002-1.074, p<0.05). Moreover, our study demonstrates that pCND does not significantly increase the risk of post-surgical complications. In our setting, pCND could have a key role in the management of DTC. The risks and benefits of pCND should be evaluated for each population to make the most appropriate therapeutic choice.

State of the Art in the Current Management and Future Directions of Targeted Therapy for Differentiated Thyroid Cancer.

Two-thirds of differentiated thyroid cancer (DTC) patients with distant metastases would be classified as radioactive iodine-refractory (RAIR-DTC), evolving into a poor outcome. Recent advances underlying DTC molecular mechanisms have shifted the therapy focus from the standard approach to targeting specific genetic dysregulations. Lenvatinib and sorafenib are first-line, multitargeted tyrosine kinase inhibitors (TKIs) approved to treat advanced, progressive RAIR-DTC. However, other anti-angiogenic drugs, including single targeted TKIs, are currently being evaluated as alternative or salvage therapy after the failure of first-line TKIs. Combinatorial therapy of mitogen-activated protein kinase (MAPK) and phosphoinositide 3-kinase (PI3K) signalling cascade inhibitors has become a highly advocated strategy to improve the low efficiency of the single agent treatment. Recent studies pointed out targetable alternative pathways to overcome the resistance to MAPK and PI3K pathways’ inhibitors. Because radioiodine resistance originates in DTC loss of differentiation, redifferentiation therapies are currently being explored for efficacy. The present review will summarize the conventional management of DTC, the first-line and alternative TKIs in RAIR-DTC, and the approaches that seek to overcome the resistance to MAPK and PI3K pathways’ inhibitors. We also aim to emphasize the latest achievements in the research of redifferentiation therapy, immunotherapy, and agents targeting gene rearrangements in advanced DTC.

Clinical and Laboratory Aspects of Thyroglobulin and Thyroglobulin Antibody in Differentiated Thyroid Carcinoma

Thyroglobulin (Tg) is a precursor for thyroid hormone, specifically synthesized by thyroid follicular cells upon stimulation by the thyroid stimulating hormone (TSH). Damage to the thyroid cells caused by benign or malignant thyroid diseases cause the release of Tg into circulation. Differentiated thyroid cancer (DTC) is the most common endocrine malignancy, which has an excellent prognosis if detected and treated early. This review describes the clinical and laboratory aspects of Tg and AntiTg measurement in the management of DTC. The serum Tg measurement has been used in the pre- and post-operative management of DTC. The clinical significance of Tg and the role its low level can play in the diagnosis and monitoring of DTC as well as in the prediction of its recurrence must be understood. DTC may lead to the production of a different Tg with novel immunogenic cancer epitopes that can induce TgAb synthesis. The preoperative TgAb level has shown a high predictive value for DTC, while postoperative serum TgAb can be used for the detection of disease persistence and recurrence. Despite the importance of TgAb level in DTC management, the presence of TgAb interferes with the analysis of Tg measurement, thus limiting its clinical utility. There is no established value regarding at which level TgAb interferes with Tg measurement. Available methods in measuring Tg and TgAb should emphasize the lower and upper limits of their detection, especially for postoperative monitoring and early disease recurrence detection. The accurate measurement of serum Tg and TgAb is pertinent to the follow-up of DTC patients, and any suspicious results must be interpreted in accordance with clinical findings in view of a present possible assay interference.

Comparison between 2015 ATA guidelines and Italian Consensus for DTC management. A commented report.

SUMMARYThe 2015 ATA guidelines and 2018 Italian Consensus have produced a series of generally concordant recommendations on clinical and therapeutic management of thyroid nodules and thyroid carcinoma. Currently, the goals of treatment are to achieve the highest disease-free survival rates through the best ratio between minimum invasiveness and cost/impact on quality of life. By analysis and comparison of the ATA Guidelines and Italian Consensus, we highlighted and commented upon the key points of differentiated thyroid cancer management. Furthermore, the aim of this work is to identify and promote uniform clinical approaches among all specialists who treat differentiated thyroid cancer and represent a starting point for a consensus drafted by the Italian Society of Otolaryngology - Head and Neck Surgery.

A multicenter, prospective study to observe the initial management of patients with differentiated thyroid cancer in China (DTCC study)

BackgroundTo assess the gaps between the initial management of patients with differentiated thyroid cancer (DTC) in real clinical practice and the recommendations of the 2012 Chinese DTC guidelines.MethodsThis multicenter, prospective study was conducted at nine tertiary hospitals across China. Eligible patients were those having intermediate or high-risk DTC after first-time thyroidectomy. During 1 year of follow-up, comprehensive medical records were collected and summarized using descriptive statistics.ResultsOf 2013 patients, 1874 (93.1%) underwent standard surgery according to the guidelines (including total lobectomy plus isthmusectomy and total/near total thyroidectomy), and 1993 (99.0%) underwent lymph node dissection; only 56 (2.8%) had postoperative complications. Overall, 982/2013 patients (48.8%) received radioactive iodine (RAI) therapy after thyroidectomy. Of all enrolled patients, 61.4% achieved the target serum thyroid-stimulating hormone level, with a median time to target of 234.0 days (95% CI: 222.0–252.0). At 1 year of follow-up, proportions of patients with excellent response, incomplete structural response, biochemical incomplete response, and indeterminate response were 34.6, 11.2, 6.6, and 47.5%, respectively; recurrence or metastasis occurred in 27 patients (1.3%). During the overall study period, 209 patients (10.4%) had at least one adverse event: 65.1% of cases were mild, 24.9% moderate, and 10.1% severe.ConclusionsThis was the first large-scale prospective study of how patients with DTC in China are treated in actual practice. Initial DTC management is generally safe and adheres to the 2012 Chinese guidelines but could be improved, and the level of guideline adherence did not produce the anticipated treatment response at 1 year of follow-up.

Management of Differentiated Thyroid Cancer: The Standard of Care.

In the past decade, the management of differentiated thyroid cancer (DTC) underwent a paradigm shift toward the use of risk stratification with the goal of maximizing the benefit and minimizing the morbidity of radioiodine (131I) therapy. 131I therapy is guided by information derived from surgical histopathology, molecular markers, postoperative diagnostic radioiodine scintigraphy, and thyroglobulin levels. 131I is used for diagnostic imaging and therapy of DTC based on physiologic sodium-iodine symporter expression in normal and neoplastic thyroid tissue. We summarize the essential information at the core of multidisciplinary DTC management, which emphasizes individualization of 131I therapy according to the patient's risk for tumor recurrence.

Can we safely reduce the administration of 131-iodine in patients with differentiated thyroid cancer? \u2013 experience of the Brugmann hospital in Brussels

Background131-iodine (131I) administration after surgery remains a standard practice in differentiated thyroid cancer (DTC). In 2014, the American Thyroid Association presented new guidelines for the staging and management of DTC, including no systematic 131I in patients at low-risk of recurrence and a reduced 131I activity in intermediate risk.The present study aims at evaluating the rate of response to treatment following this new therapeutic management compared to our previous treatment strategy in patients with DTC of different risks of recurrence.MethodsPatients treated and followed up for DTC according to the 2014-ATA guidelines (Group 2) were compared to those treated between 2007 and 2014 (Group 1) in terms of general characteristics, risk of recurrence (based on the 2015-ATA recommendations), preparation to 131I administration, cumulative administered 131I activity and response to treatment.ResultsIn total, 136 patients were included: 78 in Group 1 and 58 in Group 2. The two groups were not statistically different in terms of clinical characteristics nor risk stratification: 42.3% in Group 1 and 31% in Group 2 were classified as low risk, 38.5 and 48.3% as intermediate risk and 19.2 and 20.7% as high risk (P = 0.38). Two patients (one in each group) with distant metastases were excluded from the analysis.Preparation to 131I administration consisted in rhTSH stimulation in 23.4% of the patients in Group 1 and 100% in Group 2 (p < 0.001).131I was administered to 46/77 patients (59.7%) in Group 1 (5 at low risk of recurrence) and 38/57 patients (66.7%) in Group 2 (0 with a low risk). Among the patients treated by 131I, median cumulative activity was significantly higher in Group 1 (3.70GBq [100 mCi] range 1.11–11.1 GBq [30–300 mCi]) than in Group 2 (1.11 GBq [30 mCi], range 1.11–7.4 GBq [30–200 mCi], P < 0.001). Complete response was found in 90.9% in Group 1 vs. 96.5% in Group 2 (P = 0.20).ConclusionsUsing the 2015-ATA evidence-based guidelines for the management of DTC, meaning no 131I administration in low-risk patients, a low activity in intermediate and even high risk patients, and a systematic use of rhTSH stimulation before 131I therapy allowed us to reduce significantly the median administered 131I activity, with a similar rate of complete therapeutic response.

What is the appropriate nodular size of differentiated thyroid cancer management by Transoral Endoscopic Thyroidectomy Vestibular Approach?

Thyroid nodular disease is a common problem in clinical practice. Incidental thyroid nodules are more frequently diagnosed because of the increased access to radiologic investigations [1]. Though thyroid nodules are common, malignant cases (4.0% to 6.5% of all thyroid nodules) are clinically significant and must be precisely diagnosed. Improvements in surgical techniques have reduced perioperative morbidities. The rates of permanent recurrent laryngeal nerve (RLN) dysfunction and hypoparathyroidism are &lt;1% in experienced hands [2]. Recently, Anuwong reported that transoral endoscopic thyroidectomy vestibular approach (TOETVA) done for 60 selected cases has a low complication rate comparable to that of the conventional open thyroidectomy [3]. In this technique, endoscopic trocars were placed through a central incision in the oral vestibule and bilateral incisions in both sides of the oral commissure. The plane under the superficial fascia is entered away from the lower margin of mandibular bone to avoid damage of the marginal branch of the facial nerve as well as the facial Vessels. However, retrieval of large thyroid specimens through the central incision of the TOETVA necessitated breaking it down into smaller fragments to avoid damage of the mental nerve. This can be problematic for a suspicious or malignant differentiated thyroid cancer (DTC), whose capsule should remain intact for a precise histopathologic examination [4,5]. Imprecise pathologic diagnosis negatively impacts further treatment, follow up and prognosis. However, in this technique of TOETVA, the thyroid specimen was all put and fragmented in the retrieval bag. Supposedly, the cancer should not be spilt out during the procedure of pull out. Thyroglobulin (TG) level 3-4 weeks post-surgery can be used to assess the size of the residual thyroid mass either locally or distally, and guide remnant I-131 ablation therapy [6]. Hence, we presume the prognosis of DTC would be affected by the procedure of fragmentation of TOETVA. In this issue, we would like to establish the critical largest diameter for DTC to be removed safely (with mental nerve preservation) and completely by the TOETVA technique. In our experience, we believe that the ideal nodular size should be &lt;2.5cm to achieve safety and carcinologic goals.

Updates on the Management of Thyroid Cancer.

The diagnostic modalities, stratification tools, and treatment options for patients with thyroid cancer have rapidly evolved since the development of the American Thyroid Association (ATA) guidelines in 2015. This review compiles newer concepts in diagnosis, stratification tools and treatment options for patients with differentiated thyroid cancer (DTC), medullary thyroid carcinoma (MTC) and anaplastic thyroid cancer (ATC). Newer developments apply precision medicine in thyroid cancer patients to avoid over-treatment in low risk disease and under-treatment in high risk disease. Among novel patient-tailored therapies are selective RET inhibitors that have shown efficacy in the treatment of MTC with limited systemic toxicity compared with non-specific tyrosine kinase inhibitors. The combination of BRAF and MEK inhibitors have revolutionized management of BRAF V600E mutant ATC. Several immunotherapeutic agents are being actively investigated in the treatment of all forms of thyroid cancer. In this review, we describe the recent advances in the diagnosis and management of DTC, MTC, and ATC, with an emphasis on novel treatment modalities.