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ABSTRACT: PURPOSE: Metastatic thyroid tumors (MTT) are rare and have a poor prognosis. The aim of this retrospective study was to determine the diagnostic features and clinical outcomes of MTT. METHODS: The study subjects comprised 29 patients (age range, 37-78 years) diagnosed with MTT and treated during a 22-year period between 1987 and 2008 at a single tertiary oncology referral center. RESULTS: The primary cancer was breast cancer in 10 patients, lung cancer in six, digestive tract in six, kidney in three, head and neck in three and sarcoma in one patient. In seven patients, the diagnoses of primary cancer and MTT were synchronous. In 22 patients, the mean latency between the diagnosis of the primary cancer and MTT was 66 months (range 7 months-16 years). Based on ultrasonography (US), MTTs were classified into two categories: diffuse type (DT) (n = 9) and nodular type (NT) (n = 18). Eight patients who underwent thyroid surgery showed no survival benefit, but none needed tracheostomy. CONCLUSIONS: MTT should be considered for patients with a history of malignant disease. The findings from US are useful to diagnose MTT. Careful preoperative evaluation can avoid unnecessary thyroidectomy.
Surgery Today 01/2013; · 1.22 Impact Factor
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ABSTRACT: PURPOSE: The aim of this study is to evaluate the specificity of diagnosing PTC by fine needle aspiration (FNA) cytology. METHODS: This study retrospectively reviewed the cytopathological reports of 1066 patients that underwent thyroidectomy based on a diagnosis of PTC by FNA between January 1993 and December 2008. This study re-evaluated the cytology and histopathology of the patients that received false positive diagnoses of PTC by FNA. RESULTS: Ten patients (0.9 %) received false positive diagnoses of PTC by FNA. Three patients were overdiagnosed as having PTC by FNA cytology. In contrast, the nuclear features of PTC in the other seven cases were confirmed by the retrospective reviews of the patients' FNA cytology. Three of the seven patients showed follicular structures in their resection specimens, thus resulting in a diagnosis of either adenomatous goiter or follicular adenoma. However, PTC could not be diagnosed by histopathology in the remaining four patients, even though the histopathology showed the nuclear features of PTC. CONCLUSIONS: Most cases of PTC can be easily diagnosed by cytological and morphological atypia with certain limitations. The difficulty in diagnosing PTC by cytology is because the pathological features of PTC also occur in some benign thyroid tumors. Therefore, immunohistochemical or molecular biological approaches must be combined with current cytological diagnostic techniques for the diagnosis of PTC.
Surgery Today 10/2012; · 1.22 Impact Factor
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ABSTRACT: Extrathyroidal invasion is one of the most significant risk factors for patients with papillary thyroid carcinoma (PTC). The purpose of this study was to evaluate a novel definition of extrathyroidal invasion for patients with PTC as a method for predicting a patient's prognosis.
The prospective study was conducted for consecutive 930 patients with primary PTC who received surgery during 1993-2009. We defined only patients who had preoperative recurrent laryngeal nerve palsy or patients in whom the tumor had invaded to the mucosa of the trachea and/or esophagus as Ex3. Patients with minimal invasion were classified as Ex1, and patients with massive invasion, when we could shave off the tumors, were classified as Ex2. Patients without extrathyroidal invasion were classified as Ex0.
Patients classified Ex3 showed significantly shorter disease-free survival (p = 0.03) and disease-specific survival (p = 0.007) than patients classified Ex2. The time to recurrence at resection sites was shorter in patients classified Ex3 than in patients classified Ex2 (p = 0.02). The time to death due to distant metastasis of patients classified Ex3 was significantly shorter than that of patients classified Ex2 (p = 0.02). Within the patients classified Ex3, disease-specific survival of patients with invasion to other nearby structures was shorter than that of patients with invasion to only recurrent laryngeal nerve (p = 0.008).
The degree and site of invasion is an important prognostic factor for PTC. Our novel classification of extrathyroidal invasion is valuable in predicting the prognosis of PTC.
World Journal of Surgery 03/2012; 36(6):1231-40. · 2.36 Impact Factor
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ABSTRACT: We have previously performed retrospective analysis of patients with anaplastic thyroid carcinoma (ATC) treated between April 1976 and March 1999, revealing acute symptoms, large tumor (>5 cm), distant metastasis, and leukocytosis ≥ 10,000/mm(3) as the most important prognostic factors. We devised a novel prognostic index (PI) as the total number of these 4 factors present, giving a PI of 0-4.
We have adopted this PI since April 1999. In principle, multimodal treatment has been encouraged for a PI of ≤ 1, whereas aggressive treatment has been avoided to maintain quality of life for a PI of ≥ 3. The validity of this therapeutic strategy was prospectively investigated in 74 patients with ATC.
Six-month survival rates for PI ≤ 1 and PI ≥ 3 were 72% and 12%, respectively. Among patients with a PI of ≤ 1,11 (42%) underwent multimodal treatment and showed significantly better survival than previous cases. Survival rates did not differ between stages. For patients with a PI of ≥ 3, survival rates were equally dismal, regardless of stage. Numbers of patients who underwent tracheostomy or died from local disease were significantly decreased compared with previous cases.
Our PI is valid for anticipating prognosis and aiding timely decisions on treatment policy for ATC patients.
Surgery 12/2011; 150(6):1212-9. · 3.10 Impact Factor
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ABSTRACT: The influence of thyrotropin (thyroid-stimulating hormone [TSH]) suppressive therapy on bone mineral density (BMD) remains contentious. We have conducted a randomized controlled trial evaluating the effects of postoperative TSH suppressive therapy on disease-free survival for papillary thyroid carcinoma (PTC) since 1996, while prospectively verifying the effects of TSH suppression on BMD.
Lumbar spine BMD as expressed by T-score was examined annually in female patients randomly assigned to receive TSH suppressive therapy (group A; n = 144) or no therapy (group B; n = 127).
The mean TSH level was 0.07 ± 0.10 mU/L in group A and 3.14 ± 1.69 mU/L in group B. Group B did not show any significant decrease in T-score until 5 years postoperatively, whereas group A had a significant deterioration from 1 year postoperatively. Among group A patients, significant decreases in T-score within 1 year were seen in patients ≥ 50 years of age, but not in those <50 years of age. After 5 years of TSH suppression, 20 patients had T-scores below -2.0 and 100 patients did not. These former patients were significantly older and had lower preoperative BMD measurements than the latter.
This prospective controlled trial suggests that TSH suppression after surgery for PTC has adverse effects on BMD in women ≥ 50 years of age.
Surgery 12/2011; 150(6):1250-7. · 3.10 Impact Factor
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ABSTRACT: Although anaplastic thyroid carcinoma has a dismal prognosis, some patients show favorable survival following multimodal treatment with surgery, external irradiation and chemotherapy. However, no regimen has yet been established. We reviewed outcomes for patients who underwent a unique chemoradiotherapy regimen between 1998 and 2007.
The regimen consists of external irradiation (40 Gy at 2 Gy/day) combined with concurrent low-dose cisplatin at 5 mg/m(2) on Days 1-5, 8-12, 15-19 and 22-26, 5-fluorouracil at 200 mg/m(2) on Days 1-26 and doxorubicin at 20 mg/m(2) on Days 1 and 15. This regimen was performed on 21 patients (13 men, 8 women) with anaplastic thyroid carcinoma. Median age at the time of treatment was 66 years (range, 54-81 years).
The treatment regimen was completed in 19 patients (90%) and was interrupted in 2 (10%) due to progressive distant metastases. After excluding 10 patients who underwent complete resection before chemoradiotherapy, 1 patient (11%) showed partial response, 7 (78%) showed stable disease and 1 (11%) had progressive disease on the basis of Response Evaluation Criteria in Solid Tumors. Overall, 6-month survival rate for patients treated with chemoradiotherapy was 57%. With this novel chemoradiotherapy, death from loco-regional disease was seen in only two patients (11%). Grade 3-4 toxicities were observed in 12 patients (63%), but no treatment-related deaths were encountered.
Our new chemoradiotherapy is effective for loco-regional control of anaplastic thyroid carcinoma, particularly when combined with radical surgery. This regimen could not prevent distant metastases, but offers acceptable toxicity while maintaining patient quality of life.
Japanese Journal of Clinical Oncology 07/2011; 41(9):1074-8. · 1.78 Impact Factor
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ABSTRACT: Currently bisphosphonates are often administered to patients with osteolytic bone metastases from several neoplasms. Based on favorable experience in other cancers with bone metastases and the lack of effective treatment, we started to use zoledronic acid (ZA), a recently developed synthetic bisphosphonate drug, in the treatment of this disease. In the present study, we retrospectively evaluated the efficacy of ZA for bone metastases from differentiated thyroid carcinoma.
The study consisted of 50 patients with bone metastases from differentiated thyroid carcinoma treated at the Cancer Institute Hospital of Tokyo between 1976 and 2008. Among them, 28 patients who did not undergo bisphosphonate therapy were defined as group A and 22 patients who received ZA therapy were defined as group B. The primary efficacy endpoint for ZA treatment was the reduction in the percentage of patients who developed skeletal-related events (SREs), including bone fracture, spinal cord compression, and hypercalcemia. A secondary endpoint was the interval between a presentation of bone metastases and appearance of SREs.
SREs occurred in significantly lower frequency in group B (3 of 22 patients, 14%) than group A (14 of 28 patients, 50%) (p = 0.007). The use of ZA significantly retarded the onset of the first SRE (p = 0.04). Two group-B patients developed bisphosphonate-related osteonecrosis of the jaw.
Treatment with ZA was effective in reducing SREs or delaying their appearance in patients with bone metastases from differentiated thyroid carcinoma.
Thyroid: official journal of the American Thyroid Association 11/2010; 21(1):31-5. · 2.60 Impact Factor
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ABSTRACT: TSH suppression therapy has been used to decrease thyroid cancer recurrence. However, validation of effects through studies providing a high level of evidence has been lacking.
This single-center, open-label, randomized controlled trial tested the hypothesis that disease-free survival (DFS) for papillary thyroid carcinoma (PTC) in patients without TSH suppression is not inferior to that in patients with TSH suppression.
Participants were randomly assigned to receive postoperative TSH suppression therapy (group A) or not (group B). Before assignment, patients were stratified into groups with low- and high-risk PTC according to the AMES (age, metastasis, extension, size) risk-group classification.
For patients assigned to group A, L-T(4) was administered to keep serum TSH levels below 0.01 μU/ml. TSH levels were adjusted to within normal ranges for patients assigned to group B. Recurrence was evaluated by neck ultrasonography and chest computed tomography.
Eligible participants were recruited from 1996-2005, with 218 patients assigned to group A and 215 patients to group B. Analysis was performed on an intention-to-treat basis. DFS did not differ significantly between groups. The 95% confidence interval of the hazard ratio for recurrence was 0.85-1.27 according to Cox proportional hazard modeling, within the margin of 2.12 required to declare 10% noninferiority.
DFS for patients without TSH suppression was not inferior by more than 10% to DFS for patients with TSH suppression. Thyroid-conserving surgery without TSH suppression should be considered for patients with low-risk PTC to avoid potential adverse effects of TSH suppression.
The Journal of clinical endocrinology and metabolism 10/2010; 95(10):4576-83. · 6.50 Impact Factor
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ABSTRACT: Papillary microcarcinoma (PMC) of the thyroid generally follows a benign clinical course. However, treatment strategies remain controversial. According to our previous retrospective review of 178 patients with PMC who underwent surgery between 1976 and 1993, the most significant risk factors affecting cancer-specific survival were clinical symptoms at presentation due to invasion or metastasis. Distant metastasis and cancer-specific death were never seen postoperatively for 148 cases (83%) of asymptomatic PMC without clinically apparent (>or=1 cm) lymph node metastasis or recurrent nerve palsy. Based on these results, we identified three biologically different types of PMC that should be treated differently. Type I comprises incidentally detected PMC without any symptoms, which is harmless and the lowest-risk cancer. Conservative follow-up with ultrasonography every 6 or 12 months is feasible. Type II involves the early stage of the usual low-risk papillary carcinoma. This can be treated by lobectomy when increasing size is noted during conservative follow-up. Type III comprises clinically symptomatic PMC, representing a high-risk cancer. Immediate wider resection followed by radioiodine treatment and suppression of thyroid-stimulating hormone is recommended.
Since 1995, we have been conducting a prospective clinical trial of nonsurgical observation for asymptomatic PMC. As of 2008, 230 of 244 candidates (94%) have decided to accept this policy, whereas 56 patients underwent surgery for symptomatic PMC between 1976 and 2006.
Nonsurgical observation for a mean of 5 (range, 1-17) years for 300 lesions of asymptomatic PMC revealed that 22 (7%) had increased in size, 269 (90%) were unchanged, and 9 (3%) had decreased. No patients developed extrathyroidal invasion or distant metastasis. Three patients (1%) who developed apparent lymph node metastasis and nine patients (4%) in whom tumor increased in size eventually received surgery after 1-12 years of follow-up. No recurrences have been identified postoperatively. Conversely, 10-year cause-specific survival for symptomatic PMC was 80%. Multivariate analysis identified extrathyroidal invasion, large lymph node metastasis (>or=2 cm), and poorly differentiated component as significantly related to adverse outcomes.
Nonsurgical observation seems to represent an attractive alternative to surgery for asymptomatic PMC. Almost 95% of asymptomatic PMC patients are type I, and another 5% are type II and can be treated with conservative surgery. A small number of PMCs with bulky lymph node metastasis or extrathyroidal invasion are high-risk type III and require aggressive treatment.
World Journal of Surgery 06/2010; 34(6):1222-31. · 2.36 Impact Factor
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ABSTRACT: The treatment of bone metastasis in association with thyroid cancer represents a difficult challenge. Given the paucity of patients with bone metastasis and the difficulty of treating this disease, few studies have investigated the clinical features and prognostic factors of bone metastasis from differentiated thyroid cancer.
During the 31-year-period from 1976 to 2006, a total of 1,398 patients underwent initial thyroidectomy at Cancer Institute Hospital for differentiated thyroid carcinomas, including standard papillary thyroid carcinoma, papillary microcarcinoma (primary tumor diameter < or =1.0 cm), and follicular thyroid carcinoma. Among these, 25 (2%) patients displayed bone metastasis at initial presentation (synchronous) and 27 patients showed bone metastasis during follow-up (metachronous). The records for these 52 patients were reviewed retrospectively to identify prognostic factors and analyze treatment strategies.
Univariate analysis for disease-specific survival indicated metachronous bone metastasis and the presence of distant metastasis at sites other than bone as indicators of significantly worse prognosis. The type of cancer (papillary thyroid carcinoma versus follicular thyroid carcinoma) was not a significant indicator of prognosis; however, patients with papillary microcarcinoma showed significantly worse survival than patients with standard papillary and follicular thyroid carcinoma. A significant survival advantage was observed among patients who underwent radioactive iodine therapy, and better prognosis seemed to be obtained with greater doses of radioactive iodine. Operative resection of metastatic bone lesions also seemed to be associated with better prognosis. A multivariate analysis for disease-specific survival identified the coexistence of distant metastasis at sites other than bone as the only independent variable indicative of poor prognosis.
In the absence of definitive, effective treatments for this disease, radioactive iodine therapy combined with resection of bone metastasis, wherever possible, seems to represent the most potent therapy available. Although bone metastasis is a strong sign of poor prognosis, early detection and administration of appropriate therapy using radioactive iodine seems likely to improve the survival rate and quality of life in patients with bone metastasis from differentiated thyroid carcinoma.
Surgery 03/2010; 147(3):424-31. · 3.10 Impact Factor
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ABSTRACT: Papillary thyroid carcinoma (PTC) accounts for over 90% of all thyroid cancers in Japan. The majority of patients with PTC are categorized into a low-risk group according to the recent risk-group classification schemes, and they have excellent outcomes. Several management guidelines for thyroid cancers have been published in Western countries. However, the optimal therapeutic options for PTC remain controversial and high-level clinical evidence to resolve the issues is lacking. Moreover, socioeconomic differences in medical care exist; therefore, conventional policies for the treatment of PTC have been different between Japan and other countries. This report reviews the controversy in the treatment of PTC regarding the initial surgery, postoperative adjuvant therapies, and methods of surveillance. This review focuses on the unique policy in Japan preferring to treat patients with low-risk PTC by a less-than-total thyroidectomy without adjuvant therapies rather than a total thyroidectomy with radioactive iodine, in an attempt to maintain patients' quality of life. In addition, the institutional efforts to improve the level of evidence for the management of PTC are introduced, such as a randomized controlled trial for the effect of thyrotropin suppression therapy, a prospective study for selective lymph node dissection based on preoperative ultrasonography, and a prospective nonsurgical observation trial for asymptomatic papillary microcarcinoma.
Surgery Today 03/2010; 40(3):199-215. · 1.22 Impact Factor
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ABSTRACT: Poorly differentiated thyroid carcinoma (PDTC) was recognized as an independent clinicohistological entity of thyroid cancer in the 2004 World Health Organization (WHO) classifications, separated from papillary (PTC) and follicular carcinoma (FTC). The Turin proposal provides more specific criteria for the diagnosis of PDTC. However, in an iodine-sufficient country such as Japan, PDTC comprises <1% of all thyroid cancers. In 1983, Sakamoto analyzed pathological characteristics of PTC and FTC that recurred within 5 years after initial surgery and identified solid, trabecular, insular (STI) and scirrhous growth patterns as important predictors of poor prognosis. We re-evaluated the impact of histopathological findings on the clinical course of PTC and FTC.
Specimens from 376 consecutive cases diagnosed as PTC (n = 351) or FTC (n = 25) between 1994 and 2001 were reviewed.
Nine (2%) patients were diagnosed with PDTC according to WHO criteria. Only 1 case (0.3%) met the Turin criteria. In addition, STI components were seen in various specimens as follows: >or=50%, >or=10% but <50%, >0% but <10%, and 0% of specimens for 9 (2%), 31 (8%), 19 (5%), and 317 cases (85%), respectively. As for cause-specific survival, a significant difference was apparent between the >or=50% and >or=10% but <50% groups. Disease-free survival was identical between these groups and was significantly worse than in the >0% but <10% and 0% groups. According to multivariate analysis, histological features of STI >or=10% and squamous metaplasia were significantly related to cause-specific survival, but scirrhous infiltration, necrosis, nuclear atypia, and vascular invasion were not. The presence of STI at a level >or=10% was also a significant risk factor, together with clinical risk factors including large tumor size, large nodal metastasis, and distant metastasis. According to AMES risk-group definition, clinically high-risk patients with STI >or=10% showed the worst 10-year cause-specific survival, at 57%, irrespective of total thyroidectomy with radioactive iodine (RAI) treatment. Ten of 25 PTC patients (40%) with STI >or=10% developed cervical recurrence, whereas 9 of 15 FTC patients (60%) with STI >or=10% showed distant metastasis.
The measurement of STI >or=10% represents a distinctly important risk factor for patient survival. In particular, clinically high-risk patients with STI >or=10% need further therapy beyond RAI. Original histological pattern, as papillary or follicular, affects the site of recurrence.
World Journal of Surgery 12/2009; 34(6):1265-73. · 2.36 Impact Factor
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ABSTRACT: To define the indications for thyroid cancer surgery in elderly patients.
We compared the clinical characteristics of thyroid cancers in 85 elderly patients, defined as those aged > or =75 years, with those of 37 young patients, defined as those aged <30 years. The elderly group included patients who underwent surgery and/or reoperation and those managed nonoperatively. All patients were treated during an 11-year period from 1994 to 2004 at the Cancer Institute Hospital.
The elderly patients with papillary thyroid carcinoma had a significantly worse cumulative 5-year survival rate than the young patients with papillary thyroid carcinoma (92% vs 100%: P = 0.03). However, there was no significant difference in the survival of patients with low-risk tumors between the two age groups. The cumulative 2-year survival rate of elderly patients with a high-risk tumor was significantly lower in patients not treated with surgery than in those treated surgically (80% vs 100%: P = 0.02). Quality of life (QOL) was severely impaired in 67% and 6% of the nonoperated and operated patients, respectively.
These results suggest that surgery for thyroid cancer increases the survival rate and promotes the QOL of elderly patients if they are well enough to tolerate the procedure.
Surgery Today 01/2009; 39(8):652-7. · 1.22 Impact Factor
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ABSTRACT: Although many patients with papillary thyroid carcinoma (PTC) display associated cervical lymph node metastases (LNM), the optimal extent of lymph node dissection (LND) remains a matter of debate. Since 1993, we have performed cervical LND based on the preoperative suspicion of LNM by ultrasonography (US). We prospectively analyzed the outcomes of our "selective" LND to determine when prophylactic lateral neck dissection is advisable.
Prospective analysis was conducted for 361 consecutive patients with PTC who received initial surgery between 1993 and 2001. Mean duration of follow-up was 8.1 years. Dissection of the central compartment only was performed for patients with LNM in the central zone only and for patients with no LNM detected by US (Group A). Modified radical lateral neck dissection (MND; combined with central compartment dissection) was performed for patients diagnosed with lateral neck LNM (Group B).
Pathological LNM was found in 136 of 231 patients in Group A (59%). As for the accuracy of US diagnosis, positive predictive value was 82%. Nodal recurrences, occurring all in the lateral cervical region associated with one case of contralateral paratracheal region, was seen in 18 patients (8%) and 10-year nodal disease-free survival was 91%. Univariate analysis revealed true positive diagnosis by US, large primary tumor (> or = 4 cm), primary tumor located in the upper part of the thyroid lobe, presence of distant metastasis, extrathyroidal invasion of the primary tumor, and a poorly differentiated component of the primary tumor as significant risk factors for nodal recurrence. Among the risk factors that could be diagnosed preoperatively, distant metastasis (risk ratio, 46; p = 0.01) and large primary tumor (risk ratio, 3.6; p = 0.03) were the most important factors under multivariate analysis. Of the other 130 patients in Group B, only 3 patients had no pathological LNM (positive predictive value, 98%). Twenty-six patients (20%) developed nodal recurrence, with a 10-year nodal disease-free survival of 76%. Age (50 years or older), large nodal metastasis (> or = 3 cm), extrathyroidal invasion, and higher serum thyroglobulin level (> or =320 ng/ml) represented significant factors for nodal recurrence.
When preoperative US shows no LNM or indicates only LNM in the central compartment, dissection of the central compartment alone offers a sufficient alternative to routine prophylactic MND. However, patients with PTC demonstrating large primary tumor and/or distant metastasis were high-risk for recurrence in the lateral cervical compartment. We recommend prophylactic MND to reduce nodal recurrence for those patients.
World Journal of Surgery 10/2008; 32(11):2494-502. · 2.36 Impact Factor
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ABSTRACT: Primary hyperparathyroidism (PHPT) is known to cause diverse subjective symptoms, in addition to those related to osteitis fibrosa cystica and kidney stones. The treatment of the disease ameliorates the subjective symptoms and improves the patients' quality of life. In this prospective study, patients undergoing surgery for incidentally detected, mild, asymptomatic PHPT were assessed to determine whether subjective neuropsychological symptoms are improved even in patients with "asymptomatic" PHPT. From October 1995 to March 2004, 25 patients who had one or more neuropsychological symptoms preoperatively and were followed up 1 year after parathyroidectomy were enrolled. The subjective symptoms were identified using questionnaires distributed to patients; eight questions were used to determine the presence or absence of psychoneurological symptoms. Compared to their preoperative status, patients responded that their general health perceptions 1 year after surgery were improved (13 cases, 52%), unchanged (11 cases, 44%), or aggravated (1 case, 4%). There were no statistically significant differences in the patients' responses before and after surgery with respect to individual neuropsychological symptoms, such as "tiring easily, "forgetfulness," "decreased concentration," "depression," "irritability," "uneasiness," and "sleeplessness." Therefore, subjective neuropsychological symptoms did not improve in otherwise asymptomatic PHPT patients following parathyroidectomy. However, patients' questionnaire responses may not reflect their actual status as accurately as laboratory examination results. Overall, 52% of patients were subjectively satisfied with surgery; this may result from patients' expectations of treatment.
Archiv für Klinische und Experimentelle Ohren- Nasen- und Kehlkopfheilkunde 06/2008; 265(5):565-9. · 1.29 Impact Factor
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ABSTRACT: The presence of distant metastases is the most important predictive factor of poor outcomes in patients with papillary thyroid carcinoma (PTC). Some patients have very slow-growing distant metastases with relatively favorable outcomes, so predicting prognosis is not easy. Furthermore, many patients with distant metastases show locally advanced disease, and no consensus is available for operative control of cervical tumor in this situation.
Among 1023 patients with PTC who underwent primary thyroidectomy from 1976 to 2002, 42 patients displayed distant metastases at initial presentation and 44 patients developed distant metastases during follow-up. We reviewed the records retrospectively of these 86 patients. Mean duration of follow-up after detection of distant metastases was 7 years. Our treatment approach for patients with locally advanced neoplasms was radical resection including extensive neck dissection and extended resection of the involved organs, even when distant metastases were present.
Disease-specific survival of the 86 patients with distant metastases at 5 and 10 years was 65% and 45%, respectively. Using multivariate analysis, older age at time of distant metastases detection, distant metastases involving sites other than the lung, distant metastases diameter > or = 2 cm, presence of large nodal metastases (> or = 3 cm), and a primary neoplasm with poorly differentiated components were all predictive of worse prognosis. Our aggressive approach allowed curative resection in all but 1 patient, and only 5 patients (6%) succumbed to local disease. Patients with cervical recurrences displayed worse prognosis than those without.
Although the currently employed modalities of therapy for distant metastases do not have definitive impact on survival, some PTC patients with distant metastases, including younger patients with well-differentiated, small lung metastases appear to have relatively favorable outcomes. Local operative control of PTC is important even in patients with distant metastases, particularly when the distant metastases appear to be slow-growing.
Surgery 02/2008; 143(1):35-42. · 3.10 Impact Factor
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ABSTRACT: Recently incidental detection of papillary microcarcinoma (PMC) by means of ultrasonography (US) has increased. It is still controversial how to deal with PMC in this situation. The mortality rate of patients with PMC is generally very low, and most PMC is regarded as "innocent" cancer. However, there are a few patients with PMC that show unfavorable outcome associated with clinically evident nodal metastasis, extrathyroidal invasion and/or distant metastasis. It is important to classify patients with PMC into high-risk and low-risk group when determining the treatment method. In this paper, we introduce our strategy for patients with asymptomatic PMC, including non-surgical follow-up based on patients' informed decision.
Nippon rinsho. Japanese journal of clinical medicine 12/2007; 65(11):2045-8.
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ABSTRACT: Since the majority of multiple endocrine neoplasia type 2A (MEN 2A) patients have missense mutations at codon 634 and those with the Cys630 RET genotype mutations are extremely rare, limited clinical information is available about this rare type. We report here three members of one Japanese MEN 2A family with the Cys630Tyr genotype. A 67-year-old woman presented a firm thyroid nodule, and preoperative examination revealed medullary thyroid carcinoma with primary hyperparthyoidism and no pheochromocytoma. At surgery, bilateral medullary thyroid carcinomas and parathyroid adenoma were found. No lymph node metastasis was identified. Computed tomography scans and laboratory examination of blood have shown no evidence of tumor recurrence and no abnormality of parathyroid function during the 4 years after surgery. A 40-year-old man, the proband's son, was shown to have the same RET mutation, underwent total thyroidectomy prophylactically, and only microscopic foci of medullary thyroid carcinoma were found. A 10-year-old boy, the proband's grandson also having the same RET mutation, showed normal basal serum calcitonin level and has been followed up conservatively. To our knowledge, 18 patients of 6 families with the Cys630 mutations have been reported so far. This is only the second reported case with primary hyperparathyroidism. RET 630 mutations might be associated with lower penetrance of primary hyperparthyoidism and pheochromocytoma.
Endocrine Journal 09/2007; 54(4):531-5. · 2.03 Impact Factor
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ABSTRACT: Several factors have been proven to be useful for classifying patients with papillary thyroid carcinoma (PTC) into either low- or high-risk groups. However, the relative importance of prognostic factors, including lymph nodal metastasis, remains unclear.
A total of 604 patients who underwent initial surgery for PTC (diameter of tumor>1 cm) were analyzed. The mean duration of follow-up was 10.7 years.
By multivariate analysis for disease-specific survival, distant metastasis was the only significant risk factor (risk ratio=65.1) for younger patients (age<50). For older patients (age> or =50), distant metastasis (risk ratio=6.7), extrathyroidal invasion (risk ratio=2.4), and large nodal metastasis (> or =3 cm; risk ratio=5.3) had relative importance. From the results, younger patients with distant metastasis and older patients with any of the 3 factors were defined as at high risk, whereas the other patients were defined as at low risk. Overall, 106 patients at high risk (18%) and 498 patients at low risk (83%) had 10-year survival rates of 69% and 99%, respectively. Only 3 patients of the low-risk group died from the disease. Among postoperative factors, recurrence within 3 years after initial surgery was the most important risk factor for cancer death. Of the high-risk group, patients with a disease-free interval of >3 years showed an excellent outcome (96% of a 10-year survival rate), similar to patients in the low-risk group.
A novel classification system, in which large nodal metastases and postoperative reclassification were added, was devised. This was useful for choosing proper therapeutic strategies, offering rational information, and determining adequate postoperative follow-up schemes for individual patients with PTC.
Surgery 03/2004; 135(2):139-48. · 3.10 Impact Factor
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ABSTRACT: Although anaplastic thyroid carcinoma (ATC) is one of the most aggressive malignancies, a few patients survive for a fairly
long time after modern intensive treatment. We tried to identify prognostic factors of ATC to assist in deciding on the proper
therapeutic strategy in individual patients. Of 47 patients with ATC (1976–1999), 3 patients with “incidental” ATC (largely
differentiated thyroid carcinoma with a small region of ATC) were excluded because they had a favorable outcome. The 1-year
survival rate of the remaining 44 patients with clinically distinct ATC was 16%. The presence of acute symptoms, large tumor
(> 5 cm), distant metastasis, and leukocytosis (white blood cell count ≥ 10,000/mm3) proved to be significant risk factors. Multivariate analysis by the Cox proportional hazard model showed that these four
factors were independent factors for predicting death from ATC. We devised a novel prognostic index (PI) based on the number
of these four unfavorable characteristics the patient possessed. Patients with a PI of ≤1 had a 62% survival rate at 6 months,
whereas no patients with a PI of ≥3 survived longer than 6 months. All patients with a PI of 4 died from their disease within
3 months. Nine patients received multimodal treatment with a combination of surgery, external irradiation, and chemotherapy
and had a long survival (mean 333 ± 68 days; one patient is still alive and tumor-free), with a mean PI of 0.6. Our PI is
useful as a means of selecting patients for aggressive therapy. When the PI is low, multimodal treatment should be attempted
to obtain the best survival results; if it is high most patients are too seriously ill to tolerate intensive treatment and
palliative therapy is recommended.
World Journal of Surgery 01/2001; 25(5):617-622. · 2.36 Impact Factor
