Micropapillary Thyroid Cancer Research Articles

Accuracy and diagnostic performance of the Bethesda system for reporting thyroid cytopathology in a tertiary endocrine surgical referral center in Belgium.

The Bethesda System for Reporting Thyroid Cytopathology is a commonly used classification for fine needle aspiration (FNA) cytology of suspicious thyroid nodules. The risk of malignancy (ROM) for each category has recently been analyzed in three international databases. This paper compares the diagnostic performance of the Bethesda classification in a high-volume referral center in Belgium. All consecutive thyroid procedures were registered in a prospective database from January 2010 till August 2022. Patient and surgical characteristics, preoperative Bethesda categories, and postoperative pathology results were analyzed. Out of 2219 consecutive thyroid procedures, 1226 patients underwent preoperative FNA. Papillary thyroid cancer was the most prevalent malignancy (N=119, 70.4%), followed by follicular (N=17, 10.1%) and medullary thyroid cancer (N=15, 8.9%). Micropapillary thyroid cancer was incidentally found in 46 (3.8%) patients. Bethesda categories I, II, III, IV, V, and VI, respectively, represented 250 (20.4%; ROM 4.4%), 546 (44.5%; ROM 3.8%), 96 (7.8%; ROM 20.8%), 231 (18.8%; ROM 15.2%), 62 (5.1%; ROM 72.6%), and 41 (3.3%; ROM 90.2%) patients. Overall ROM was 13.8%. An negative predictive value (NPV) of 96.2% was found. Overall specificity was 64.2% with a positive predictive value (PPV) of 31.9%. Diagnostic accuracy was 67.8%. Compared to international databases (CESQIP, EUROCRINE, and UKRETS), ROM in this study appeared lower for Bethesda category IV (15.2 vs. 26.7% and p=0.612). Despite being validated in numerous studies, ROM based on preoperative FNA cytology classified according to the Bethesda classification may vary among surgical centers and countries as this study reveals a higher NPV and lower PPV.

Efficacy of ultrasound-guided radiofrequency ablation of papillary thyroid microcarcinoma after one year

ObjectiveThis study aims to evaluate the feasibility and safety of percutaneous radiofrequency ablation guided by ultrasound for treating papillary thyroid microcarcinoma. MethodAt our institution, fifty people who had been treated for micropapillary thyroid cancer with ultrasound-guided radiofrequency ablation were chosen. Thyroid function was evaluated after one month, and the volume of the ablation region was assessed immediately, 3, 6, and 12 months after treatment. At the same time, the complications or adverse reactions after treatment were evaluated. ResultsAs time passed, the volume of the ablation area decreased gradually, showing a regression trend. There was a significant difference in the volume of the ablation area between adjacent groups (P < 0.05), and the tumor volume reduction ratio (VRR) of the ablation area was a statistically significant difference between adjacent groups (P < 0.05). There was no significant difference between the indexes related to thyroid function before and after treatment(P > 0.05). No local recurrence or distant metastasis was found during follow-up; The most common complication after the operation was a slight pain in the neck. A few patients had toothache and neck swelling symptoms, and the above symptoms subsided within 24 h after the operation. ConclusionUltrasound-guided radiofrequency ablation is safe and effective for treating single-focus micropapillary thyroid carcinoma while retaining thyroid function, with few and minor complications, which can be used as an ideal surgical option.

Age-standardized incidence, mortality rate, and trend changes of thyroid cancer in the Balearic Islands during the 2000-2020 period: a population-based study.

Global thyroid cancer (TC) incidence is growing worldwide, but great heterogenicity exists among published studies, and thus, population-specific epidemiological studies are needed to adequate health resources and evaluate the impact of overdiagnosis. We conducted a Public Health System database retrospective review of TC incident cases from 2000 to 2020 in the Balearic Islands region and evaluated age-standardized incidence rate (ASIR), age at diagnosis, gender distribution, tumor size and histological subtype, mortality rate (MR), and cause of death. Estimated annual percent changes (EAPCs) were also evaluated and data from the 2000-2009 period were compared to the 2010-2020 period when neck ultrasound (US) was routinely performed by clinicians at Endocrinology Departments. A total of 1387 incident cases of TC were detected. Overall, ASIR (×105) was 5.01 with a 7.82% increment in EAPC. A significant increase in the 2010-2020 period was seen for ASIR (6.99 vs 2.82, P < 0.001) and age at diagnosis (52.11 vs 47.32, P < 0.001) compared to the 2000-2009 period. A reduction in tumor size (2.00 vs 2.78 cm, P < 0.001) and a 6.31% increase in micropapillary TC (P < 0.05) were also seen. Disease-specific MR remained stable at 0.21 (×105). The mean age at diagnosis for all mortality groups was older than survivors (P < 0.001). The incidence of TC has grown in the 2000-2020 period in the Balearic Islands, but MR has not changed. Beyond other factors, a significant contribution of overdiagnosis to this increased incidence is likely due to changes in the routine management of thyroid nodular disease and increased availability of neck US.

Current patterns of care in low-risk thyroid cancer-A national cross-sectional survey of Australian thyroid clinicians.

De-escalated treatment of hemithyroidectomy without radioactive iodine (RAI) is now accepted for patients with low-risk, well-differentiated thyroid cancer (WDTC). The benefit of long-term follow-up care remains controversial. This study aims to describe parameters associated with less than total thyroidectomy, and discharge from specialist follow-up in patients with low-risk WDTC in Australia. An online survey was distributed to Australian members of Endocrine Society of Australia, Australian and New Zealand Endocrine Surgeons, and Australian Society of Otolaryngology, Head and Neck Surgery. Clinicians completed a survey of management and follow-up care preferences for four clinical vignettes (all low-risk WDTC). 119 clinicians (48% endocrinologists, 55% male) answered at least one question. The majority (59%) of respondents recommended less than total thyroidectomy and omission of RAI in patients with WDTC <2 cm. Most (62%) would discharge a patient with micropapillary thyroid cancer within 1 year following total thyroidectomy. In contrast, for WDTC 1-4 cm, >90% of clinicians would continue specialist follow-up for at least 5 years. The majority of clinicians felt that patients experienced disproportionate fear of recurrence and were reassured by follow-up. After multivariable analysis, clinicians who participated in multidisciplinary teams (MDTs) were more likely to choose de-escalated care for both initial treatment (p = .005) and follow-up care (>5 years, p = .05). Clinician attitudes captured by this survey reflect recent changes in guidelines towards hemithyroidectomy for low-risk WDTC, particularly amongst MDT attendees. There is a need to further examine the impact of de-escalated care on fear of recurrence and quality of life in thyroid cancer survivors.

RF11 | PSAT249 Radiofrequency Ablation for Thyroid Nodules: The First Ecuadorian Prospective Cohort

Abstract Introduction Radiofrequency ablation (RFA) is a promising, non-surgical method, used for the treatment of benign and malignant thyroid nodules (TN). While this minimally invasive technique has been studied extensively in Europe and Asia, it has been recently adopted in Latin America. The aim of our study is to describe the clinical outcomes following the first cohort of TN subjected to ablative radiofrequency in Ecuador. Methods This single-center, prospective study, carried out at ITECC (Instituto de la Tiroides y Enfermedades de Cabeza y Cuello) in Ecuador, included adults who underwent RFA for benign and malignant thyroid nodules (TN), between September 2020 and January 2022. The trans-isthmic approach and moving shot technique using the RF Medical equipment with an 18G needle and 5 or 7 mm tip were applied. Nodule size and volume, thyroid function, and complications were evaluated before and after RFA. Initial volume and change in TN volume were calculated with the ATA calculator and the independent-samples T-test. Results A total of 26 patients with 28 TNs were included. 25 TNs were benign (Bethesda II) and 3 were micropapillary thyroid cancer (MPTC) (Bethesda VI). In the benign lesions group, most were female (82.6%), &amp;lt;55 years of age (73.9%), euthyroid (62.5%), and symptomatic (95.6%); had a mean maximum diameter of 3.3 ± 1.3 (range: 0.8–5.5) cm and a mean initial volume of 13.1 ± 11.6 ml; and had predominantly solid component (36.4%). A substantial volume reduction was observed since the first month after RFA (1 month: mean volume 8.6 ± 4.2 ml, p=0.01; 6 months: mean volume 4.5 ± 3.9 ml, p=0.04; and 12 months: mean volume 4.9 ± 6.9 ml, p=0.25; vs. baseline). All patients were asymptomatic at the last follow-up. In the MPTC group, two patients were males (66.7%); all were &amp;lt;55 years of age (100.0%) and euthyroid (100.0%); most were asymptomatic diagnosed by routine US (66.7%); had a mean maximum diameter of 0.6 ± 0.1 (range: 0.5–0.8) cm and a mean initial volume of 0.056 ± 0.001 ml. At 1-month follow-up after RFA all TN were fibrosed and no lymph node or distant metastases were found. Finally, in both groups, no major complications were found and only one patient reported ecchymosis at the puncture site. Thyroid function was not affected. Conclusions To the best of our knowledge, we are the pioneers in Ecuador and the third country, after Brazil and Colombia, in Latin America that implemented RFA in the management of TN. In our first experience, RFA was a safe and effective technique. RFA induced a substantial volume reduction, improved symptoms, avoided cosmetic concerns, and did not affect normal thyroid function. Our results are consistent with other series. Data on a longer follow-up are needed to confirm long-term efficacy. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m.

Update on the Evaluation of Thyroid Nodules.

Thyroid nodules (TN) are prevalent in the general population and represent a common complaint in clinical practice. Most are asymptomatic and are associated with a 7%-15% risk of malignancy (1). Methods: PubMed and Medline were searched for articles with a focus on the epidemiology, diagnosis, and management of TN over the past 5 y. Results: The increase in frequency of imaging has led to a rise in the incidence of incidentally diagnosed TN. The initial evaluation of a TN includes assessing thyroid function, clinical risk factors, and neck imaging. Ultrasound remains the gold standard for assessing TN morphology, and biopsy is the standard method for determining whether a TN is benign. Recently published risk stratification systems using morphologic characteristics on ultrasonography have been effective in reducing the number of unnecessary biopsies. Advances in molecular testing have reduced the number of surgical procedures performed for diagnostic purposes on asymptomatic TN with indeterminate cytology. Scintigraphy is the first-line study for assessing a hyperfunctioning nodule. Many TN can be followed clinically or with serial ultrasound after the initial diagnosis. Surgical intervention is warranted when local symptoms are present, in patients with clinical risk factors, as well as in most situations with malignant cytology. Active surveillance is an option in cases of micropapillary thyroid cancer. Emerging nonsurgical approaches for treating TN include ethanol ablation for TN; sclerotherapy for thyroid cysts; and thermal techniques, such as radiofrequency ablation, laser ablation, microwaves, and high-intensity focused ultrasound. Conclusion: Most TN are benign and can be safely monitored. The indications for biopsy and frequency of imaging should be tailored on the basis of risk stratification. Treatment options should be individualized for each patient's particular situation. Active surveillance should be considered in certain cases of papillary microcarcinoma.

Long-Term Results of Ultrasound-Guided Radiofrequency Ablation of Benign Thyroid Nodules: State of the Art and Future Perspectives-A Systematic Review.

BackgroundNearly 20 years after the first feasibility study, minimally invasive ultrasound (US)-guided therapeutic techniques are now considered as a safe and effective alternative to surgery for symptomatic benign thyroid nodules. Radiofrequency ablation (RFA) is one of the most widely used treatment in specialized thyroid centers but, due to the relatively recent introduction into clinical practice, there are limited long-term follow-up studies. Aim of our work was to review the outcomes of RFA on solid nonfunctioning and on autonomous thyroid nodules (AFTN) on a long-time period for assessing the results in term of efficacy, complications, and costs and to compare them to the current indications of RFA.MethodsA systematic review was performed using EMBASE and Medline library data between 2008 and 2021. Seventeen studies evaluated RFA for the treatment of benign solid (nonfunctioning or autonomous) thyroid nodules, with an at least 18 months of follow-up. Data extraction and quality assessment were performed by two endocrinologist according to PRISMA guidelines. Anthropometric data, safety and efficacy parameters were collected.ResultsThe majority of the studies was retrospective study and reported 933 nodules, mostly solid. Baseline volume ranged between 6.1 ± 9.6 and 36.3 ± 59.8 ml. Local analgesia was used and the time duration of the treatment was between 5 ± 2 and 22.1 ± 10.9 min. The volume reduction rate at 12 months ranged from 67% to 75% for the nodule treated with a single procedure and reached to 93.6 ± 9.7% for nodules treated with repeat ablations. The regrowth rate at 12 months ranged from 0% to 34%.ConclusionAll the studies under examination consistently validated the long-term clinical efficacy and the substantial safety of RFA for the treatment of benign thyroid nodules. Thermal ablation, however, is an operator-dependent technique and should be performed in centers with specific expertise. The selection of the patients should be rigorous because the nodule size and the structural and functional characteristics influence the appropriateness and the outcomes of the treatment. Future perspectives as the treatment of micro-papillary thyroid cancer or cervical recurrence need further investigations.

Ectopic thyroid tissue in lateral cervical lymph nodes: a case report

Background: Ectopic thyroid tissue is a rare condition, especially when present inside lateral cervical lymph nodes. Only two similar cases have been reported. Case Presentation: A case of ectopic thyroid tissue in the lymph nodes of the lateral neck in a 34-year-old woman is reported, leading to a challenging differential diagnosis between micropapillary thyroid cancer with skip metastases or recurrent ectopic thyroid tissue. As a definitive diagnosis could not be made based on imaging or cytology, a diagnostic hemithyroidectomy was performed in combination with a total lateral neck dissection to avoid future ectopic thyroid tissue recurrence. Conclusion: The presence of ectopic thyroid tissue in the lateral neck is rare, especially when present within the lymph nodes themselves. Important differential diagnosis with a thyroid malignancy must be made. Benign causes, such as ectopic thyroid tissue, are diagnoses by exclusion.

MMP-9 1562 C/T polymorphism may be associated with an increased susceptibility to develop micropapillary thyroid cancer but not more advanced tumours

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

The predictors of malignancy in thyroid nodules with atypia of undetermined significance or follicular lesions of undetermined significance

Aim: This study aimed to evaluate clinical, radiological and laboratory (neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios, and mean platelet value) features that may better define the rate of malignancy in order to contribute to the management of thyroid nodules with AUS/FLUS.Material and Methods: The data of patients with histologic findings of AUS/FLUS on FNA, who underwent surgery at General Surgery Department in a tertiary care hospital between January 2012 and December 2019, were reviewed retrospectively. The patients with any other malign and/or inflammatory diseases and continued on corticosteroid therapy and/or chemotherapy were excluded.Results: The current study included 60 patients (73.3% women), who underwent surgery for 62 thyroid nodules classified as AUS/FLUS. The specimen pathology revealed a thyroid malignancy in 16 patients, including 10 patients with papillary cancer, 5 patients with micro-papillary thyroid cancer, 1 patient with minimally invasive follicular carcinoma. Ten patients had follicular adenoma. The remaining 35 patients (37 nodules) had nodular colloidal hyperplasia and/or chronic lymphocytic thyroiditis. The rates of malignancy (ROM) and neoplasia (RON) were 25.8% and 40.3%, respectively. Nearly half of the cases (41.9%) had chronic lymphocytic thyroiditis. The malignancy rate in cases with chronic lymphocytic thyroiditis was 26.9%, which was similar in cases without (25%). In multivariate analysis, only microcalcifications were found to be positively associated with malignancy (p: 0.1; [OR] 5.185; CI95% 1.4-19.18). Conclusion: Chronic lymphocytic thyroiditis may lead to overestimation of AUS/FLUS results. It was not associated with malignancy in thyroid nodules with AUS/FLUS. Inflammatory values, such as NLR, PLR and MPV, were not useful markers of malignancy. Among all variables only US findings (microcalcifications according to the current study) may be useful in risk-stratification of malignancy in thyroid nodules with AUS/FLUS.

OR19-4 High Prevalence of Primary Hypothyroidism in Patients with Alkaptonuria Eighteen Years of Experience

Background: Alkaptonuria (AKU) is a rare autosomal recessive disorder caused by pathogenic variants in the gene encoding homogentisate-1,2-deoxygenase (HGD). Deficiency of HGD leads to tissue deposition of homogentisic acid (HGA), causing severe osteoarthropathies, aortic and mitral valve degeneration and kidney stones. HGD is vital for the catabolism of tyrosine, which provides the backbone of iodination into thyroxine (T4) within the thyroid gland. The goal of this study was to assess thyroid function (TFT) in patients (pts) with AKU. Methods: We performed a cohort study including pts with AKU followed at our center between 2000 and 2018. All pts had thyroid stimulation hormone (TSH), freeT4 (fT4), anti-thyroid peroxidase antibodies (anti-TPO-abs) measured repeatedly by immunoassay. In addition, a subset of patients underwent a thyroid ultrasound (US). Hypothyroidism (HYPO) was defined as TSH above the reference range (0.27-4.2 mIU/ml) with fT4 below the reference range (0.9-1.7 ng/dl) on two repeated tests or normalization of TSH on levothyroxine (LT4) replacement therapy. Subclinical HYPO (S-HYPO) was defined as TSH above the reference range with normal fT4 on two repeated tests. Results:The study cohort consisted of 130 pts with AKU, majority men (55.4%), aged 59.1±15 years and followed for 36 (range 1-63) months, during which median 10 (range 2-35) TFTs were performed. Twenty-four pts were diagnosed with HYPO, but 3 pts were excluded due to post-thyroidectomy etiology of HYPO, giving a prevalence of HYPO of 16.5% (21/127) - significantly higher than reported 5% of the general population (p=0.006). S-HYPO was diagnosed in 4.7% (6/127) and overt HYPO in 11.8% (15/127) pts, who were treated with a median LT4 dose of 100 mcg daily (1.4 mcg/kg). The median thyroid volume in HYPO pts was 7 cc (range 3.9-13). The prevalence of elevated anti-TPO-abs in the whole cohort was 14% (18/127), while its prevalence in HYPO group was 43% (9/21) - significantly lower than reported 89.8% for HYPO pts in the general population (p<0.001). Among 49 pts who had thyroid US performed, thyroid nodules with a median size of 0.4 (range 0.3-3.2) cm were identified in 59.2% (29/49), similar to prevalence observed in general population (p=0.63). Three pts (6%) were diagnosed with thyroid cancer (TC), 2 - with micro-papillary TC and 1 with Hurthle cell TC. The prevalence of TC was similar to prevalence observed in general population (p=0.77). Conclusions: AKU is associated with high prevalence of primary HYPO. The etiology of HYPO is unclear, given low prevalence of anti-TPO-abs in hypothyroid AKU pts. Further functional studies are needed to assess potential pathologic effect of the accumulation of HGA on thyroid hormone synthesis and function.

Predictors for central lymph node metastases in CN0 papillary thyroid microcarcinoma (mPTC): A retrospective analysis of 1304 cases

Presence of lymph node metastases increases the risk of recurrence, but prophylactic central neck node dissection for patients with micropapillary thyroid cancer (mPTC) is controversial. We aim to find the clinical predictors of central lymph node metastases (CLNM) in patients with cN0 mPTC. We retrospectively reviewed the clinicopathological and molecular genetic characteristics of 1304 patients with cN0 mPTC operated at the First Hospital of Jilin University between January 1, 2013 and May 31, 2016, all underwent thyroid lobectomy or total thyroidectomy with unilateral or bilateral prophylactic central neck dissection. Univariate and multivariate analysis were used to identify the predictors of CLNM. 30.7% of cN0 mPTC patients had CLNM. Univariate analysis found CLNM to be associated with younger age (≤45), male gender, larger tumor (>0.5cm), multifocality, bilaterality, capsular invasion, lymphovascular invasion and extrathyroidal infiltration, but not associated with BRAF mutation, tumor location, preoperative TSH and anti-thyroglobulin antibody level. Multivariate logistic regression showed age ≤45 years (p<0.001, OR=2.05), male gender (p<0.001, OR=1.94), tumor size >0.5cm (p<0.001, OR=1.87), bilaterality (p=0.003, OR=1.86) and capsular invasion (p=0.013, OR=1.49) to be independent predictors for CLNM in cN0 mPTC patients. Prophylactic central neck dissection has higher yield for cN0 mPTC patients with age ≤45 years, male gender, tumor size>0.5cm, bilaterality and capsular invasion. BRAF mutation is not a predictor for CLNM in cN0 mPTC patients.

Puzzle over active surveillance for micropapillary thyroid carcinoma.

It is worth distinguishing between the two strategies of management for low risk micropapillary thyroid cancer (MPTC). Immediate therapy, whereas active surveillance (AS) entails delivering curative treatment on signs of disease progression. AS appears to reduce overtreatment in patients with low-risk MPTC without compromising cancer-specific survival at 10 years. Therefore, AS is an option for select patients who want to avoid the side-effects inherent to the different types of immediate treatment. However, inclusion criteria for AS and the most appropriate method of monitoring patients on AS have not yet been standardized.

Differential expression of PIWIL2 in papillary thyroid cancers

Thyroid cancer is the most common type of endocrine malignancy and a leading cause of death among endocrine organ-related cancers. Similar to other types of cancers, early diagnosis of thyroid cancer is important to increase the survival and treatment of this disease. Several immunohistochemical markers are used in the differential diagnosis of thyroid papillary carcinoma. Also, increasing evidence indicates that P-element induced wimpy testis like 2 (PIWIL2) is an RNA-binding protein involved in the induction and progression of numerous types of human malignancies such as lung, breast, colon, prostate and cervix cancers. However, the role of PIWIL2 was poorly investigated in thyroid cancers. Accordingly, aim of the present study was to elucidate the relationship between PIWIL2 and thyroid cancers. The expression level of PIWIL2 was determined by analyzing both protein and mRNA levels in papillary and micropapillary carcinoma tissues by using immunohistochemistry and real-time PCR methods, respectively. Immunohistochemical analysis of HBME-1, galectin-3 and CK-19 was also performed. Similar to other immune markers of HBME-1, galectin-3 and CK-19, protein expression levels of PIWIL2 was significantly up-regulated in both papillary and micropapillary thyroid cancers (p < 0.01). Moreover, consistent with protein expression levels, mRNA expression levels of PIWIL2 was elevated in both papillary and micropapillary thyroid cancer tissues. Yet, mRNA expression changes were statistically insignificant. In conclusion, results of the current study suggest that PIWIL2 can be involved in thyroid cancer tumorigenesis and can be used as a novel predictive biomarker and/or therapeutic target.

Current trends of practical issues concerning micropapillary thyroid carcinoma: The Korean Society of Thyroid-Head and Neck Surgery.

Although several thyroid associations have published various guidelines, controversies especially in cases of micropapillary thyroid cancer (MPTC) still exist. This survey was designed to collect information about diagnostic tests and treatments performed on patients with MPTC and help identify current trends in thyroid surgery.We developed questionnaires about the management methods for MPTC, which were used to identify factors related to indications of fine needle aspiration (FNA), type of surgery, and central lymph node dissection (CLND). Active 60 members of the Korean Society of Thyroid-Head and Neck Surgery participated in the study in September 2016.Ultrasound-guided FNA was usually initiated when the tumor was at least 5 mm (60%). All respondents preferred ultrasound-guided FNA and surgery for nodules with extrathyroidal extension (ETE). The preferred treatment option for intraglandular MPTC was lobectomy (92%) rather than active surveillance (8%). Posterolateral ETE increased the respondents’ preference for total thyroidectomy (61.7%). Active surveillance was preferred for tumors <5 mm, which was decreased by the presence of ETE. The presence of ETE (73.3%) and its proximity to critical organs (46.7%) were the main determining factors for prophylactic CLND. For multiple metastatic lymph nodes at level III, selective neck dissection including levels IIb (23.3%) and V (78.3%) was preferred in addition to levels IIa, III, VI, and V.Korean head and neck surgeons favored total thyroidectomy and CLND in cases wherein ETE, central lymph node metastasis, or critical organ involvement was suspected.

Cost-effectiveness of active surveillance versus hemithyroidectomy for micropapillary thyroid cancer

The management of low-risk micropapillary thyroid cancer <1cm in size has come into question, because recent data have shown that nonoperative active surveillance of micropapillary thyroid cancer is a viable alternative to hemithyroidectomy. We conducted a cost-effectiveness analysis to help decide between observation versus operation. We constructed Markov models for active surveillance and hemithyroidectomy. The reference case was a 40-year-old patient with recently diagnosed, low-risk micropapillary thyroid cancer. Costs and health utilities were determined using extensive literature review. The willingness-to-pay threshold was set at $100,000/quality-adjusted life year gained. Deterministic and probabilistic sensitivity analyses were performed to account for uncertainty in the model's variables. Active surveillance is dominant (less expensive and more quality-adjusted life years) for a health utility <0.01 below that for disease-free, posthemithyroidectomy state, or for a remaining life expectancy of <2years. For a utility difference ≥0.02, the incremental cost-effectiveness ratio (the ratio of the difference in costs between active surveillance and hemithyroidectomy divided by the difference in quality-adjusted life years) for hemithyroidectomy is <$100,000/QALY gained and thus cost-effective. For a utility difference of 0.11-the reference case scenario-the incremental cost-effectiveness ratio for hemithyroidectomy is $4,437/quality-adjusted life year gained. The cost-effectiveness of hemithyroidectomy is highly dependent on patient disutility associated with active surveillance. In patients who would associate nonoperative management with at least a modest decrement in quality of life, hemithyroidectomy is cost-effective.

Incidental Finding of Papillary Thyroid Carcinoma in the Patients with Primary Hyperparathyroidism.

The relationship between primary hyperparathyroidism (pHPT) and papillary thyroid cancer (PTC) still remains unclear. We aimed to investigate the incidence of the co-existence of pHPT and PTC. Between 2010 and 2013, all patients with pHPT were retrospectively reviewed and those undergoing concomitant thyroid surgery were recorded. Of these, patients with a pathological result showing papillary or micro-papillary thyroid cancer were included into the study. A chart review of 228 patients who underwent surgery for pHPT revealed 86 (37.7%) patients with concurrent thyroid disease requiring surgical treatment. Thyroid cancer was noted in six female patients (6.9%) undergoing thyroid resection, and 2.6% of all patients with pHPT. Four patients underwent total thyroidectomy while lobectomy was applied in the remaining two. None of the cases with lobectomy required a completion thyroidectomy. We demonstrated the concurrence of PTC and pHPT at a rate of 2.6% which appeared as a coincidental pathology; however, thyroid disorders, seen in one of three patients with pHPT, were not uncommon. Further research is still needed to develop a reliable explanation for relationship between pHPT and non-medullary thyroid cancer.

Observation for newly diagnosed micro-papillary thyroid cancer: is now the time?

Observation for newly diagnosed micro-papillary thyroid cancer: is now the time?

Thyroid pathologies accompanying primary hyperparathyroidism: a high rate of papillary thyroid microcarcinoma.

Thyroid pathologies and non-medullary thyroid cancer often accompany primary hyperparathyroidism (PHPT). The purpose of this study was to examine the association between thyroid diseases, especially micropapillary thyroid cancer, with PHPT. Data regarding 46 patients who were operated on with a diagnosis of PHPT at Inonu University Faculty of Medicine, General Surgery Clinic between June 2009 and March 2013 were retrospectively analyzed. Age, gender, levels of preoperative calcium, parathyroid hormone and phosphorus, and the histopathological results of the removed parathyroid and thyroid tissues were evaluated. All of the patients had a preoperative diagnosis of PHPT and there was no history of radiation to the head and neck region in any of the patients. Out of the 46 patients who were operated on for PHPT, 39 were female and 7 were male. The mean age was 52.8 years (25-76). Simultaneous thyroidectomy was performed in 35 patients (76.1%) due to an accompanying thyroid disorder. Papillary microcarcinoma was detected in 5 of these 35 (10.9%) patients who underwent thyroidectomy, two of which (40%) were multifocal tumors. The benign thyroid pathologies detected in the remaining 30 (65.2%) cases included lymphocytic thyroiditis in 3, Hashimoto thyroiditis in 1, follicular adenoma in 3 (two of which was Hurtle cell), and nodular colloidal goiter in 23 patients. The preoperative serum phosphate level was significantly higher in the group with papillary thyroid microcarcinoma (p=0.013). In regions where goiter is endemic, thyroid diseases and thyroid papillary microcarcinoma occur in association with PHPT at a higher rate compared to the normal population. Therefore, we believe that patients who are planned for surgery due to PHPT should be thoroughly investigated for the presence of any concomitant malignant thyroid pathologies in the preoperative period. It should also be kept in mind that patients with high blood serum phosphate values may have an increased risk of papillary thyroid microcarcinoma.

Incidental papillary thyroid carcinoma: Clinical characteristics and prognostic factors among patients with Graves’ disease and euthyroid goiter, Cleveland Clinic experience

ObjectiveThe prevalence and clinical significance of incidental differentiated thyroid cancer (DTC) in patients with Graves’ disease (GD) remain uncertain. Thyroid stimulating antibody (TSI Ab)-titers were thought to be responsible for the potentially increased incidence or aggressiveness of PTC in that setting. The aim of this study was to compare the prevalence of incidental DTC among patients with GD and euthyroid goiter (EG), to assess the ability of TSI to predict DTC in GD and to investigate the clinical features that may predict incidental DTC in GD and EG. MethodsTwo hundred and forty eight patients with EG and 245 patients with GD patients who had undergone total thyroidectomy at our institution between 2005 and 2013 were retrospectively selected from our data base. An analysis of incidentally discovered DTC was conducted comparing GD group with EG group. ResultsIncidental micro-papillary thyroid cancer (MPTC) was found in 28% in EG group, as compared to 26% in GD group. PTC Patients with GD were significantly younger (44 vs 59) and less likely to have compressive symptoms than with EG before surgery (p<0.001). In GD group, patients with MPTC were also significantly older (p=0.009) than those without, were more likely to have symptomatic goiter (p<0.001), and to have a nodular disease (p<0.001). TSI ab titer did not predict MPTC in GD group (The AUC curve was 0.55 (95% CI: 0.46, 0.64). Among patients with GD and incidental MPTC, 58% of patients had at least one nodule. ConclusionThe prevalence of incidental DTC in GD is comparable to EG. Each is increased compared to general population. Age of presentation of PTC was significantly lower in GD suggesting an increased risk for MPTC in GD. Nodule size greater than 1cm predicted incidental DTC whereas TSI ab titers and disease duration did not.