Paritosh Suman

Risk factors for central lymph node metastasis in papillary thyroid carcinoma: A National Cancer Data Base (NCDB) study

BACKGROUND There is no consensus regarding prophylactic central lymph node dissection (pCLND) in patients with papillary thyroid carcinoma (PTC). Identification of risk factors for central lymph node metastasis (CLNM) in patients with PTC could assist surgeons in determining whether to perform selective pCLND. METHODS The National Cancer database was queried from 1998 to 2011 for patients with clinical staging T1-4cN0M0 PTC. All patients underwent near, sub-, or total thyroidectomy with or without pCLND. Univariate and multivariable logistic regressions were performed on the following clinical variables: age, sex, race and tumor size as risk factors for pathologic CLNM (pN1a). RESULTS In 39,562 patients with T1-4cN0M0 PTC, 61% underwent pCLND. Patients with age >45 years, African American race, tumor size ≤ 1 cm, unifocal tumors, follicular variant PTC, no insurance, and treatment at community cancer facilities were less likely to have pCLND (P < .001). In the pCLND group, 15.6% of patients had CLNM. On adjusted multivariable logistic regression, age ≤ 45 years, Asian race, male sex, and larger tumors were statistically significantly associated with CLNM. CONCLUSION Age ≤ 45 years, Asian race, male sex, and larger tumors are associated with the presence of CLNM, which allows for selective pCLND in PTC.

TIMING OF RADIOACTIVE IODINE THERAPY DOES NOT IMPACT OVERALL SURVIVAL IN HIGH-RISK PAPILLARY THYROID CARCINOMA

OBJECTIVE Postthyroidectomy radioiodine (RAI) therapy is indicated for papillary thyroid carcinoma (PTC) with high-risk features. There is variability in the timing of RAI therapy with no consensus. We analyzed the impact of the timing of initial RAI therapy on overall survival (OS) in PTC. METHODS The National Cancer Data Base (NCDB) was queried from 2003 to 2006 for patients with PTC undergoing near/subtotal or total thyroidectomy and RAI therapy. High-risk patients had tumors >4 cm in size, lymph node involvement, or grossly positive margins. Early RAI was ≤3 months, whereas delayed was between 3 and 12 months after thyroidectomy. Kaplan-Meier (KM) and Cox survival analyses were performed after adjusting for patient and tumor-related variables. A propensity-matched set of high-risk patients after eliminating bias in RAI timing was also analyzed. RESULTS There were 9,706 patients in the high-risk group. The median survival was 74.7 months. KM analysis showed a survival benefit for early RAI in high-risk patients (P = .025). However, this difference disappeared (hazard ratio [HR] 1.26, 95% confidence interval [CI] 0.98-1.62, P = .07) on adjusted Cox multivariable analysis. Timing of RAI therapy failed to affect OS in propensity-matched high-risk patients (HR 1.09, 95% CI 0.75-1.58, P = .662). CONCLUSION The timing of postthyroidectomy initial RAI therapy does not affect OS in patients with high-risk PTC. ABBREVIATIONS CI = confidence interval CLNM = cervical lymph node metastasis FVPTC = follicular variant papillary thyroid carcinoma HR = hazard ratio KM = Kaplan-Meier NCDB = National Cancer Data Base OS = overall survival PTC = papillary thyroid carcinoma RAI = radioactive iodine.

Response to commentary on: Risk factors for central lymph node metastasis in papillary thyroid carcinoma: A National Cancer Data Base (NCDB) study

Background. There is no consensus regarding prophylactic central lymph node dissection (pCLND) in patients with papillary thyroid carcinoma (PTC). Identification of risk factors for central lymph node metastasis (CLNM) in patients with PTC could assist surgeons in determining whether to perform selective pCLND. Methods. The National Cancer database was queried from 1998 to 2011 for patients with clinical staging T1-4cN0M0 PTC. All patients underwent near, sub-, or total thyroidectomy with or without pCLND. Univariate and multivariable logistic regressions were performed on the following clinical variables: age, sex, race and tumor size as risk factors for pathologic CLNM (pN1a). Results. In 39,562 patients with T1-4cN0M0 PTC, 61% underwent pCLND. Patients with age >45 years, African American race, tumor size #1 cm, unifocal tumors, follicular variant PTC, no insurance, and treatment at community cancer facilities were less likely to have pCLND (P< .001). In the pCLND group, 15.6% of patients had CLNM. On adjusted multivariable logistic regression, age #45 years, Asian race, male sex, and larger tumors were statistically significantly associated with CLNM. Conclusion. Age #45 years, Asian race, male sex, and larger tumors are associated with the presence of CLNM, which allows for selective pCLND in PTC. (Surgery 2015;j:j-j.)

First-Line Therapy for Anaplastic Thyroid Cancer: Operation Versus Medical Management

Anaplastic thyroid cancer (ATC) is a highly lethal disease. First-line therapy for a patient diagnosed with this disease includes surgical resection or chemoradiation. Due to variable treatment and its rarity, there is a paucity of prospective and/or randomized controlled literature studying the initial therapy for patients diagnosed with ATC. To understand which therapy is more appropriate in terms of survival and quality of life, we evaluated the available literature and our own institutional experience with the management of ATC for recommendations regarding this topic. This chapter provides a summary of the pertaining literature and offers recommendations based on these sources for first-line management of a patient with newly diagnosed ATC.

CONCORDANCE OF PRE-OPERATIVE CLINICAL STAGE WITH PATHOLOGIC STAGE IN PATIENTS ≥45 YEARS OLD WITH WELL-DIFFERENTIATED THYROID CANCER

OBJECTIVE Clinical stage (cStage) in thyroid cancer determines extent of surgical therapy and completeness of resection. Pathologic stage (pStage) is an important determinant of outcome. The rate of discordance between clinical and pathologic stage in thyroid cancer is unknown. METHODS The National Cancer Data Base was queried to identify 27,473 patients ≥45 years old with cStage I through IV differentiated thyroid cancer undergoing surgery from 2008-2012. RESULTS There were 16,286 (59.3%) cStage I patients; 4,825 (17.6%) cStage II; 4,329 (15.8%) cStage III; and 2,013 (7.3%) cStage IV patients. The upstage rate was 15.1%, and the downstage rate was 4.6%. For cStage II, there was a 25.5% upstage rate. The change in cStage was a result of inaccurate T-category in 40.8%, N-category in 36.3%, and both in 22.9%. On multivariate analysis, the patients more likely to be upstaged had papillary histology, tumors 2.1 to 4 cm, total thyroidectomy, nodal surgery, positive margins, or multifocal disease. Upstaged patients received radioiodine more frequently (75.3% vs. 48.1%; P<.001). CONCLUSION Approximately 20% of cStage is discordant to pStage. Certain populations are at risk for inaccurate staging, including cT2 and cN0 patients. Upstaged patients are more likely to receive radioactive iodine therapy. ABBREVIATIONS CI = confidence interval; cStage = clinical stage; DTC = differentiated thyroid cancer; NCDB = National Cancer Data Base; OR = odds ratio; pStage = pathologic stage; RAI = radioactive iodine.