Camille Buffet

Scoring system for predicting recurrences in patients with papillary thyroid microcarcinoma.

CONTEXT Papillary thyroid microcarcinomas (PMC) defined as tumors ≤10 mm in diameter (including pT1a and pT3 according to the latest pTNM classification) have good prognosis, although recurrence is possible. Clinicians are interested in using a scoring system for predicting recurrences. OBJECTIVE To identify the prognostic factors for recurrence in patients with PMC and to develop a scoring system based on lymph node involvement, multifocality, and sex. To determine the impact of extrathyroidal invasion (ETI) and a threshold value for analyzing multifocality. METHODS Single-center retrospective study of a cohort of 1669 patients with PMC managed from 1960 to 2007. The Kaplan-Meier survival rate and prognostic factors of events were analyzed using log-rank tests and uni- and multivariate Cox model-based analyses. A scoring system was proposed. RESULTS Sixty-eight recurrences were observed. Initial lymph node metastases (P=0.0001), multifocality (P=0.05), and male sex (P=0.01) were significantly associated with recurrence, although there was a period effect (after 1990). PMC size was not a significant variable. Our scoring system allows us to separate patients into three risk groups according to their recurrence-free probability. For PMC Nx patients, total foci size of multifocal tumors >20 mm was significantly associated with recurrence (P<0.0001). Radioiodine (RAI) ablation was associated with better outcome only in PMC with ETI. CONCLUSION Our scoring system classifies recurrence risk. In PMC Nx patients, multifocality is important in planning therapeutic strategies. Recurrence probability of pT3 PMC appears lower if RAI ablation is performed.

The incidence of papillary thyroid carcinoma and outcomes in operative patients according to their body mass indices

BACKGROUND The connection between high body mass index (BMI), risk of papillary thyroid carcinoma (PTC), and the aggressiveness of PTC is still debated. We aimed to establish the relationship between excess BMI and the risk of PTC in an operative population, and the impact of obesity on histopathologic aggressiveness of PTC and on the outcome of patients. METHODS All consecutive patients who underwent thyroid operation from June 2002 to December 2009 were reviewed in this retrospective study. BMI groupings were based on standardized categories: normal-weight, overweight, and obesity. We performed a total thyroidectomy with lymph node dissection in patients with preoperative or operative diagnosis of PTC. Radioiodine ablation was performed in every N1 patient, in case of tumor size greater than 10 mm, and if there was extrathyroidal invasion. During a median follow-up of 6.2 years, patients who were retreated by operation or (131)I were considered to have a persistent (<18 months of the initial operative treatment) or recurrent (≥ 18 months) disease. RESULTS Of 6,684 patients who had a thyroid gland resection, we identified 1,216 (18.2%) patients with PTC. Patients who were overweight or obese were not at greater risk of PTC than normal-weight subjects. Indications for operation or radioiodine therapy were similar in the three BMI groups. During follow-up, 86 patients (7.1%) experienced persistent (4.5%) or recurrent (2.5%) disease. When excluding micro-PTCs (≤ 10 mm), we found an association between recurrent or residual locoregional thyroid cancer and BMI: 18.7% in obese patients versus 8.5% if BMI <25 kg/m(2) and 9.8% if 25 ≥ BMI < 30 kg/m(2) (P = .03). This difference was clearly marked for persistence. When adjusted for other cofounder factors, we observed that BMI was an independent factor associated with the risk of postoperative locoregional event (odds ratio 3.8, 95% confidence interval 1.6-8.8), with sex, age, lymph node metastasis, and tumor bilaterality. CONCLUSION In macro-PTC, obese patients had an increased risk of developing a locoregional event during the follow-up, specifically a persistence of the disease. According to these results, overweight and obese patients with macro-PTC should be monitored more carefully for early detection of cancer persistence.

Hypertrophic Osteoarthropathy and Follicular Thyroid Cancer: A Rare Paraneoplastic Syndrome

Background: Hypertrophic osteoarthropathy (HOA) is a rare condition characterized by bone and joint pain and digital clubbing usually associated with bronchopulmonary diseases. Primary HOA is rare and the pathogenesis remains unclear. Objectives: Cases of HOA as a paraneoplastic syndrome associated with thyroid carcinoma are very rare - only 2 cases have been described in the literature. Results: We present the first case of a 40-year-old patient affected by HOA associated with invasive differentiated follicular thyroid carcinoma operated in 2 stages. Both operations were followed by radioiodine ablation, and then a rapid unresectable local recurrence developed requiring cervical radiotherapy (70 Gy). A second treatment with 100 mCi of 131I confirmed it was a refractory thyroid cancer. Further surgery confirmed a poorly differentiated follicular cancer and 12 cycles of chemotherapy by gemcitabine and oxaliplatin followed. During the 8 years of follow-up, cervical recurrence was stable, but severe episodes of hemoptysis occurred requiring iterative embolization of the bronchial and tracheal arteries. Other lung diseases were excluded. Digital clubbing appeared, which was associated with arthritis, bone pain and inflammatory syndrome. X-rays and magnetic resonance imaging found periosteal apposition in the long bones; bone scintigraphy confirmed the HOA diagnosis. Other causes of arthritis were eliminated. She was treated with colchicine, corticosteroids and nonsteroidal anti-inflammatory drugs, but only the combination of methotrexate and hydroxychloroquine reduced the morphine requirements. Conclusion: HOA is exceptionally associated with thyroid cancer and we raised the hypothesis of the secretion of a circulating factor in a patient with invasive and recurrent follicular thyroid cancer, refractory to radioiodine.

TIRADS score is of limited clinical value for risk stratification of indeterminate cytological results

CONTEXT Thyroid nodules with cytological indeterminate results represent a daily and recurrent issue for patient management. OBJECTIVE The primary aim of our study was to determine if TIRADS (Thyroid Imaging Reporting and Data System) could be used to stratify the malignancy risk of these nodules and to help in their clinical management. Secondary objective was to estimate if this risk stratification would change after reclassification of encapsulated non-invasive follicular variant of papillary carcinomas (FVPTC) as non-invasive follicular thyroid neoplasm (NIFTP). PATIENTS AND METHODS Single-center retrospective study of a cohort of 602 patients who were referred for ultrasound-guided fine-needle aspiration from January 2010 to December 2016 with an indeterminate cytological result and in whom histological results after surgery were available. TIRADS score was prospectively determined for all patients included. Nodules that had been classified as FVPTC were submitted to a rereading of histological report and reclassified as NIFTP when judged relevant. A table of malignancy risk crossing Bethesda and TIRADS results was built before and after this reclassification. RESULTS The study included 602 cytologically indeterminate nodules. TIRADS score was positively correlated with the malignancy rate (P < 0.0001). Risk stratification with TIRADS was significant only in Bethesda V nodules (P = 0.0004). However, the risk of malignancy in this Bethesda V category was always above 45%, whatever the TIRADS score. CONCLUSION For a clinician facing an indeterminate cytological result for a thyroid nodule, return to TIRADS score is of limited value in most conditions to rule in or rule out malignancy and to guide subsequent management of patients.

Horst Schleusener, 1933-2015

his inaugural lecture on ‘The Regulation of TSH Synthesis and Secretion’. Together with Jürgen Quabbe and Wolfgang Oelkers, he created a competitive, academic Department of Endocrinology at Steglitz. Thyroid research gained momentum in the 1960s due to innovations in biochemistry and nuclear physics in medicine and immunology. Radioimmunoassays were introduced in thyroid testing and these allowed functional diagnostics for the first time. Schleusener’s first PubMed-listed publication with his colleague F.A. Horster described the ‘biological test for the thyrotropic hormone’ [1] , and paved the way for further research. In 1967, together with K. Schimmelpfennig and F.A. Horster, he received the first Schöller-Junkmann prize, awarded by the German Endocrine Society (DGE). This award was Horst Schleusener passed away on 12 July 2015. From the late 1960s to the 1990s of the last century, he was a leading figure in thyroidology in Germany and Europe. Born, raised and educated in Berlin, a wartime city that then got divided, he studied medicine at the Free University, from which he graduated in 1959. His academic focus on the thyroid came about by serendipity. Once asked by Werner Scherbaum why he had become a thyroidologist, he revealed that Gotthard Schettler, the head of his medical department at the time (later to become director of the Heidelberg University Hospital), advised him to choose the organ that started with an alphabetic alliteration to his surname, i.e. ‘Schilddrüse’ (thyroid). He remained faithful to this organ throughout his professional life. After his internship, he went to work for 18 months with J. Maxwell McKenzie at the Canadian McGill University of Montreal, where he further characterised the long-acting thyroid stimulator. According to his wife Annerose Schleusener, who accompanied him, this must have been one of the happiest periods of his life. After his return to Germany, he established a research group funded by the German Research Foundation (DFG), the Federal Ministry of Education and Research (BMBF) and others. In 1969, he advanced to the senior position of ‘Oberarzt’ (consultant/senior registrar), and was in the group of physicians under Max Schwab, who developed the structure of internal medicine in the Klinikum Steglitz (now known as Campus Benjamin Franklin) in Berlin. In 1971, his habilitation treatise was approved and he gave Published online: October 28, 2015