Differentiated thyroid carcinoma: comparison between papillary and follicular carcinoma in a single institute

PURPOSE: To compare and contrast the clinical presentation and treatment outcome of patients with papillary and follicular thyroid carcinoma and to study the pattern of practice of treatment of differentiated thyroid carcinoma in Hong Kong. METHOD: The clinical presentation and treatment outcomes were reviewed for 1057 patients with differentiated thyroid cancers who were treated at the Queen Elizabeth Hospital, Hong Kong, from 1960 to 1997. Eight hundred forty-two patients had papillary thyroid carcinomas (PTC), and 215 had follicular thyroid carcinomas (FTC). The mean follow-up was 9.2 years. RESULTS: The differences in the clinical factors of PTC to FTC were as follows: PTC had a higher incidence (3.9:1); these patients were younger at presentation (median age, 44 vs 49), showed a higher female-male ratio (4.5 vs 2.9) and smaller primary tumor size (median 2 cm vs 3.5 cm), and a higher incidence of multifocal disease (28.3% vs 18.1%), extrathyroidal extension (39.4% vs 14%), and more lymph node metastases (33.3% vs 12.1%). The incidence of distant metastases was higher for patients with FTC (28.8% vs 8.9%), and cause-specific survival rates were lower (p =.001). The locoregional control rates were not significantly different (p =.2). The 10-year cause-specific survival, freedom from distant metastasis, and locoregional failure figures for PTC compared with FTC were 92.1% vs 81%, 90.8% vs 72.3%, and 78.5% vs 83%. CONCLUSIONS: Although patients with PTC tend to have more advanced locoregional disease compared with those with FTC, the likelihood of locoregional control is similar, and the probability of cure is better.     

Papillary and follicular variant of papillary carcinoma of the thyroid: Initial presentation and response to therapy

INTRODUCTION: The 2 most common histologic variants of papillary carcinoma are pure papillary carcinoma (PTC) and follicular variant of papillary thyroid carcinoma (FVPTC). The purpose of this study is to compare the presentation and short-term response to therapy of these variants and to determine if FVPTC is a more aggressive form of thyroid cancer that warrants intensive therapy. METHODS: A retrospective chart review of patients treated for PTC and FVPTC between 1996 and 1999 was performed. Clinical variables were compared with the Wilcoxon Rank-Sum test or the Fischer's Exact Test. RESULTS: Of 160 patients with papillary thyroid carcinoma included, 114 (71%) had PTC and 46 (29%) had FVPTC. Mean follow-up was 38.6 months. FVPTC presented with larger tumors (median 1.5 cm vs 1.0 cm, P = 0.007) and higher tumor stage than PTC. PTC patients were more likely to present with local invasion and to have local recurrence (9.65% vs 0% for both variables). There were no significant differences in patient age, gender, vascular invasion, lymph node or distant metastases, surgical treatment, radioactive iodine therapy, remission, or mortality. CONCLUSION: FVPTC presented with larger original tumor size and higher tumor stage but a lower local invasion rate and recurrence rate than patients with PTC despite similar therapies. These data suggest that FVPTC and PTC carry similar prognoses in early stages and that FVPTC may have a reduced predilection for local invasion. Although further studies with longer follow-up are required, these results do not suggest that FVPTC warrants more aggressive therapy than PTC.     

The diagnostic dilemma of follicular variant of papillary thyroid carcinoma

BACKGROUND: Given the difference in surgical management between follicular neoplasms and papillary thyroid carcinoma (PTC), we sought to determine the sensitivity of fine-needle aspiration (FNA) and intraoperative pathologic study (IP), frozen section and cytologic study, in establishing a diagnosis of follicular variant of papillary thyroid carcinoma (FVPTC) and how these techniques impact operative management. METHODS: A retrospective chart review was performed of patients who underwent thyroidectomy for nodular disease between June 1997 and June 2002 identifying patients with a final diagnosis of FVPTC. FNA and IP results were reviewed in this group of patients and correlated with those of final histopathologic study. The sensitivity of FNA and IP was calculated. RESULTS: Eighty-two patients had a final diagnosis of FVPTC. Eighty-six preoperative FNAs were obtained in 80 patients, leading to a diagnosis of PTC in 7 (sensitivity 9%). Intraoperative pathologic study was performed in 31 patients with suspicious FNA results, of which 13 were definitive for PTC (sensitivity 42%). Overall, IP was obtained in 42 patients, of which 15 were positive for PTC (sensitivity 36%). CONCLUSION: Although the sensitivity of FNA in establishing a diagnosis of FVPTC is low, FNA identifies patients with suspicious lesions in whom IP is important in guiding operative management.     

Conservative management of patients with intrathyroidal well-differentiated follicular thyroid carcinoma.

BACKGROUND: Total or near-total thyroidectomy for the treatment of follicular thyroid carcinoma (FTC). The prognosis of patients with low-risk FTC, however, is excellent, and thus total thyroidectomy may not be justifiable in such patients. METHODS: A retrospective review identified 61 patients diagnosed with intrathyroidal well-differentiated FTC between 1958 and 1991. RESULTS: Median age at diagnosis was 42 years (range, 15-78 years). Most patients (90.2%) had a lobectomy or subtotal thyroidectomy. Median tumor size was 3.0 cm (range, 0.9-9.5 cm). Fifty-eight patients (95.1%) received thyroid hormone supplementation, and 5 (8.2%) received radioactive iodine ablation postoperatively. Median follow-up was 11 years (range, 3-35 years). Local recurrence, metastasis, or both developed in 3 patients (4.9%), and all subsequently died of thyroid cancer. The cumulative 10- and 15-year cancer-specific survival rate was 96.5%. Factors significantly related to worse survival were oxyphilic histology (log-rank, P =.00) and tumor size of more than 4 cm (P =.001). However, neither was found to be an independent predictor of outcome by Cox multivariate analyses (P =.7 and.9, respectively). The extent of initial operation (unilateral versus bilateral procedure) was not significantly related to survival (P =.52). CONCLUSION: Conservative management consisting mainly of lobectomy or subtotal thyroidectomy and thyroid hormone supplementation is associated with favorable outcome of patients with intrathyroidal well-differentiated FTC.     

Prognostic factors of insular versus papillary/follicular thyroid carcinoma

The study aims were to characterize patients with insular thyroid cancer and to provide data on patient outcome after surgical therapy. We compared nine patients with insular thyroid cancer at the Department of Surgical Science of "La Sapienza" University of Rome with 27 patients of similar age and tumor size who had follicular and papillary cancer, for a minimum follow-up period of 24 months (range, 24-72 months). All of the patients examined underwent total thyroidectomy. Vascular invasion was observed in 44.4 per cent of insular carcinomas (P < 0.05 vs papillary carcinomas). No significant differences were observed regarding diagnostic method, multifocality, tumor nodes metastases (TNM), or stage. The death rate of patients with insular carcinoma (33.3%) was found to be higher than that of patients with follicular carcinoma (P < 0.05) and papillary carcinoma (P < 0.01). Relapsing lymph-node pathologies were observed in 4 patients (44.4%) with insular carcinoma (P < 0.05 vs those with follicular and papillary carcinomas). Distant metastases were observed in 66.6 per cent of insular carcinomas (P < 0.005 vs follicular carcinoma and P < 0.001 vs papillary carcinoma). At the end of follow-up, 2 patients (22.2%) with insular carcinoma were disease-free (P < 0.001 vs those with follicular and papillary carcinomas). Our study demonstrates an unfavorable prognostic role of the insular phenotype of thyroid cancer, such that this tumor can be classified as an autonomous clinical and pathological entity.     

Differentiated thyroid carcinoma. Surgery and significance of lymph node involvement.]

INTRODUCTION: Nodal treatment in papillary (PTC) and in follicular (FTC) thyroid carcinoma is still a subject of debate. METHODS: 1974-95 therapeutic lymphadenectomy (30/95), 1996-1999 frequent prophylactic lymphadenectomy (32/57; P = 0.005) was used for PTC, with therapeutic lymphadenectomy for FTC (15/115). 131I was used selectively for pN1-tumours. RESULTS: PTC: The incidence of pN0-, but not of pN1-status increased significantly (P = 0.03). Nodal recurrence was observed in 5/89 (6%) with therapeutic, vs. 1/54 (2%) with prophylactic lymphadenectomy (P = NS), i.e. in 1/107 (0.9%) patients without evidence of nodal disease, vs. 5/36 (14%) of those with pN1-status (P = 0.0004). Survival at 25 yrs. in stages TNM I and II was 100%, i.e., independent of N-status. FTC: No nodal recurrence was observed. CONCLUSION: Occult untreated nodal disease represented no major clinical problem. Selective nodal treatment may offer optimal results; meticulous nodal dissection is indicated for N1-tumours.     

Follicular thyroid carcinoma: the role of histology and staging systems in predicting survival

OBJECTIVE: To evaluate the risk factors including tumor histomorphology for survival specific to follicular thyroid carcinoma (FTC) and to apply commonly employed staging systems in predicting survival for patients with FTC. SUMMARY BACKGROUND DATA: FTC is usually analyzed collectively with papillary thyroid carcinoma (PTC) in risk group analysis. Risk factors and risk group analysis are important in the management of patients with FTC, although current published therapeutic guidelines call for total thyroidectomy followed by radioactive iodine (I) ablation for all FTC patients. METHODS: Over a 40-year period, 156 patients surgically treated for FTC with an average follow-up of 14.4 years were retrospectively studied after histologic reclassification according to the type and degree of invasiveness of the tumor. Potential risk factors for survival were calculated using multivariate analysis, and the prognostic accuracy of AMES risk group stratification, UICC/AJCC pTNM staging, Degroot classification, and MACIS scoring schemes in predicting survival was compared. RESULTS: Seventeen (11%) patients had distant metastases at presentation, and bilateral thyroid resection was performed for 131 (84%) patients. Seventeen (11%) patients died of recurrent or metastatic disease. The overall and cancer-specific survival (CSS) rates at 10 years were 79% and 88%, respectively. None of the patients with minimally invasive (n = 49) or angioinvasive (n = 23) carcinomas died compared with 17 of 84 patients with widely invasive carcinomas (P = 0.0007). Using the Cox proportional hazards model, old age, the presence of distant metastases, and incomplete tumor excision were independent prognostic factors for survival. For patients who underwent curative treatment, old age and widely invasive carcinoma were risk factors for poor survival. All staging systems studied accurately predicted CSS, and the pTNM UICC/AJCC staging system yielded the best prognostic information. CONCLUSIONS: Commonly adopted staging systems can be applied specifically to patients with FTC. The distinction of FTC in minimally invasive and widely invasive carcinoma based on the extent of invasiveness rather than vascular invasion is important in identifying low-risk FTC patients for a more conservative management.     

Lymphknotendissektion beim papillären und follikulären Schilddrüsenkarzinom

BACKGROUND: There is still unresolved debate about the optimal surgical management of papillary (PTC) and follicular (FTC) thyroid cancer regarding lymph node dissection. So far the German guidelines recommend the same extent of surgery for both tumors. PATIENTS AND METHODS: This study is based on 626 patients with PTC and 191 with FTC from a group of 1062 own patients with thyroid malignancies. The extent of surgery, tumor size, and pN status were analysed. The results were compared with those in the current literature. RESULTS: Tumors 25 mm. CONCLUSION: Due to prevalence and importance of lymph node metastasis differing between PTC and FTC, we recommend treating both tumor entities differently. For PTC a more extended lymph dissection is necessary, even in tumors 相似文献   

The prevalence and prognostic value of BRAF mutation in thyroid cancer

OBJECTIVE: To examine the prevalence of BRAF mutation among thyroid cancer histologic subtypes and determine the association of BRAF mutation with indicators of poor prognosis for papillary thyroid cancer and patient outcome. SUMMARY BACKGROUND DATA: The appropriate extent of surgical treatment, adjuvant therapy and follow-up monitoring for thyroid cancer remains controversial. Advances in the molecular biology of thyroid cancer have helped to identify candidate markers of disease aggressiveness. A commonly found genetic alternation is a point mutation in the BRAF oncogene (BRAF V600E), which is primarily found in papillary thyroid cancer and is associated with more aggressive disease. METHODS: BRAF V600E mutation status was determined in 347 tumor samples from 314 patients with thyroid cancer (245 with conventional papillary thyroid cancer, 73 with follicular thyroid cancer, and 29 with the follicular variant of papillary thyroid cancer). Univariate and multivariate analyses were performed to determine the association of BRAF V600E with clinicopathologic factors and patient outcome. RESULTS:: The prevalence of BRAF V600E mutation was higher in conventional papillary thyroid cancer (51.0%) than in follicular variant of papillary thyroid cancer (24.1%) and follicular thyroid cancer (1.4%) (P < 0.0001). In patients with conventional papillary thyroid cancer, BRAF V600E mutation was associated with older age (P = 0.0381), lymph node metastasis (P = 0.0323), distant metastasis (P = 0.045), higher TNM stage (I and II vs. III and IV, P = 0.0389), and recurrent and persistent disease (P = 0.009) with a median follow-up time of 6.0 years. Multivariate analysis showed that BRAF V600E mutation [OR (95% CI) = 4.2 (1.2-14.6)] and lymph node metastasis [OR (95% CI) = 7.75 (2.1-28.5)] were independently associated with recurrent and persistent disease in patients with conventional papillary thyroid cancer. CONCLUSIONS: BRAF V600E mutation is primarily present in conventional papillary thyroid cancer. It is associated with an aggressive tumor phenotype and higher risk of recurrent and persistent disease in patients with conventional papillary thyroid cancer. Testing for this mutation may be useful for selecting initial therapy and for follow-up monitoring.     

Cytoplasmic accumulation of alpha-catenin in thyroid neoplasms

BACKGROUND: Alpha-catenin (alpha-cat) is one of the anchoring proteins of E-cadherin. It has been shown that deviation in its function may alter the cadherin-catenin complex leading to disturbed cell-cell adhesion. Immunohistochemical studies have shown that cytoplasmic localization of alpha-cat in tumors is associated with aggressive behavior. In this study, we evaluated the expression of alpha-cat in various thyroid tumors by immunohistochemical analysis. METHODS: Fifty cases were selected:18 papillary carcinoma classic type (PTC), 9 follicular variant of PTC (FVPTC), 6 follicular carcinoma (FCA), 4 anaplastic carcinoma (ACA), 8 follicular adenoma (FA), 3 nodular goiter (NG), and 2 lymphocytic thyroiditis (LT). The staining reaction was classified as membranous, cytoplasmic, or both. The intensity of the staining was graded as negative (0), weak (+), moderate (++), and strong (+++). RESULTS: Staining along the cell membrane was observed in 36 (72%) and cytoplasmic expression was present in 28 (57%) cases. The cytoplasmic staining was more commonly seen in malignant lesions; it was more common in PTC (78% of all PTC) than follicular patterned lesions (FVPTC, FCA). All cases of ACA (4 of 4) showed only cytoplasmic expression. No correlation was found between lymph node involvement and alpha-cat staining patterns. CONCLUSIONS: Cytoplasmic expression of alpha-cat is more common in (1) malignant lesions of thyroid and (2) PTC than FVPTC and FCA. The lack of membrane and presence of cytoplasmic expression suggest a role of alpha-catenin in the aggressive biology of ACA.     

The value of thyroid peroxidase immunohistochemistry for preoperative fine-needle aspiration diagnosis of the follicular variant of papillary thyroid cancer

BACKGROUND: With the use of May-Grunwald-Giemsa staining, cytologic features of the follicular variant of papillary thyroid cancers (FVPTCs) on thyroid fine-needle aspiration (FNA) often resemble those of hyperplastic and adenomatous nodules. Detection of reduced staining after thyroid peroxidase (TPO) immunohistochemistry with monoclonal antibody MoAb47 has been shown to be a helpful diagnostic marker. The purpose of this study was to assess the value of TPO immunohistochemistry for the diagnosis of FVPTC. METHODS: Of 3505 patients with adequate FNA samples, 1576 patients underwent surgical procedures. Histologic examination of the surgical specimen demonstrated papillary thyroid cancer in 227 cases, including 42 FVPTCs (18%). The diagnostic accuracy of standard thyroid FNA and TPO immunohistochemistry, which we use routinely, was compared in these 42 FVPTCs. RESULTS: Standard FNA allowed accurate diagnosis of malignancy in 32 of the 42 FVPTCs and in 170 of the 185 typical papillary thyroid cancers. TPO-immunohistochemistry staining was accurate in all 42 FVPTCs and in 182 of 185 typical PTCs. CONCLUSIONS: FVPTC is a frequent source of false-negative results on standard thyroid FNA. This study shows that TPO immunostaining accurately demonstrates malignancy in these tumors.     

Clinicopathologic significance of histologic vascular invasion in papillary and follicular thyroid carcinomas

BACKGROUND: The association of angioinvasion with tumor aggressiveness in follicular and papillary thyroid carcinoma remains unclear. This study addresses this problem focusing on clinicopathologic relevance of angioinvasion in the treatment of papillary thyroid carcinoma and follicular thyroid carcinoma. METHODS: From a university hospital database, 358 patients with papillary thyroid carcinoma or follicular thyroid carcinoma were randomly selected. Their charts were retrospectively analyzed and divided into papillary thyroid carcinoma and follicular thyroid carcinoma groups. Each group was subdivided into angioinvasive and nonangioinvasive tumor subgroups. All data were analyzed using Student's t-test, Mann-Whitney rank sum test, chi-square test, and Fisher's exact test. RESULTS: There were 289 women and 69 men, ages 18 to 89 years. Papillary thyroid carcinoma (86%) was more frequent than follicular thyroid carcinoma. Most patients had nonangioinvasive tumor (90.2%). After a mean followup of 43.6 months, there were no significant differences between papillary thyroid carcinoma subgroups for local recurrence (p = 0.69), persistent elevated serum thyroglobulin (p = 0.568), and distant metastasis rates (p = 0.422). No death related to the cancer was observed in both papillary thyroid carcinoma subgroups (p = 1), except for one death resulting from a concomitant nasopharyngeal cancer. The longterm prognosis was less favorable for angioinvasive papillary thyroid carcinoma based on AJCC (American Joint Committee on Cancer staging), AMES (age, distant metastasis, tumor extent, and size), and MACIS (distant metastasis, age, completeness of primary tumor resection, local invasion, and tumor size), but the angioinvasive papillary thyroid carcinoma were larger than nonangioinvasive papillary thyroid carcinomas. The short-term clinical outcomes in both follicular thyroid carcinoma, after a mean followup of 72.3 months, were comparable in terms of local recurrence (p = 0.34), persistent elevated serum thyroglobulin (p = 1), and distant metastasis (p = 0.597). There was no death related to cancer in both follicular thyroid carcinoma subgroups (p = 1). There were no significant differences between both follicular thyroid carcinoma subgroups for longterm prognosis. CONCLUSIONS: Our results indicate that angioinvasion does not adversely influence short-term outcomes or longterm prognosis in follicular thyroid carcinoma and short-term outcomes in papillary thyroid carcinoma. Angioinvasion is a postoperative pathologic finding that does not justify an ominous prognosis or drastic therapeutic measures.     

Thyroid surgery in the geriatric patient

BACKGROUND: Although age itself is no contraindication for major surgical procedures, few patients 75 years and older undergo thyroid surgery. HYPOTHESIS: Thyroid surgery in the geriatric patient can be performed with low morbidity and mortality. DESIGN: Retrospective analysis of prospectively documented data. SETTING: University hospital referral center. PATIENTS: We included 738 patients undergoing thyroid surgery within 5 years, of whom 55 (7.5%) were 75 years or older (group 1) (mean +/- SD age, 79.9 +/- 4.1 years). MAIN OUTCOME MEASURES: Indication for surgery, surgical strategy, morbidity, and mortality were analyzed and compared with those in younger patients (<75 years; group 2). RESULTS: Malignancy was suspected or verified in 29 patients (52.7%) in group 1; 21 (38.2%) had mechanical symptoms due to large bilateral nodular goiters; and 5 (9.1%) presented with benign nodular goiter. The main indication in group 2 (n = 683) was benign nodular goiter in 455 (66.6%); 142 patients (20.8%) presented with suspected malignancy and 21 (3.1%) with mechanical symptoms (P<.001). Most patients underwent total thyroidectomy, hemithyroidectomy, or near-total thyroidectomy (n = 50 [90.9%; group 1] vs n = 597 [87.4%; group 2]; P =.53). Frequency of malignancy was higher in group 1 ([n = 20 [36.4%] vs n = 179 [26.2%]; P =.17). Morbidity of thyroid surgery was comparable in both groups. One (2.3%) of 44 patients in group 1 had permanent hypoparathyroidism, compared with 10 (2.0%) of 502 in group 2 (P =.61); permanent recurrent laryngeal nerve paralysis occurred in 1 (1.05%) of 95 nerves at risk in group 1 compared with 3 (0.26%) of 1172 nerves at risk in group 2 (P =.22). There was no perioperative mortality in either group. CONCLUSIONS: Thyroid surgery in patients 75 years or older can be performed with low morbidity. The guarantees for success include an individual risk-and-benefit analysis and careful preoperative preparation.     

Chronic mesenteric ischemia: open surgery versus percutaneous angioplasty and stenting

OBJECTIVE: The aim of the study was to evaluate the safety and efficacy of percutaneous angioplasty and stenting (PAS) in comparison with traditional open surgical (OS) revascularization for the treatment of chronic mesenteric ischemia. METHODS: Over a 3.5-year period, 28 patients (32 vessels) underwent PAS (balloon angioplasty alone, 5 [18%] of 28; angioplasty and stenting, 23 [82%] of 28) for symptoms of chronic mesenteric ischemia. These patients were compared with a previously published series of 85 patients (130 vessels) treated with OS (bypass grafting, 60 [71%] of 85; transaortic endarterectomy, 19 [22%] of 85; or patch angioplasty, 6 [7%] of 85). RESULTS: The PAS and OS groups were similar with respect to baseline comorbidities, duration of symptoms (median: 6.7 vs 10.5 months, P =.52), and the number of vessels involved, but the patients differed in their age at presentation (median: 72 vs 65 years, P =.005). Fewer vessels were revascularized per patient in the PAS group (1.1 +/- 0.4) compared with the OS group (1.5 +/- 0.6, P =.001). Overall, 85.7% (24/28) had one vessel and 14.3% (4/28) had two vessels revascularized in the PAS group versus 48.2% (41/85) with one-vessel and 47.1% (40/85) with two-vessel revascularization in the OS group. No difference was noted in the early in-hospital complications (median: 17.9% [PAS] vs 32.9% [OS], P =.12) or mortality rate (10.7% [PAS] vs 8.2% [OS], P =.71). A reduced length of hospital stay in the PAS patients did not attain statistical significance (median: 5 days [PAS] vs 13 days [OS], P =.08). Although the 3-year cumulative recurrent stenosis (P =.62) and mortality rate (P =.99) did not differ, the PAS treatment group had a higher incidence of recurrent symptoms (P =.001). CONCLUSION: Although the results of PAS and OS were similar with respect to morbidity, death, and recurrent stenosis, PAS was associated with a significantly higher incidence of recurrent symptoms. These findings suggest that OS should be preferentially offered to patients deemed fit for open revascularization.     

Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience

INTRODUCTION: Endovascular therapy (percutaneous transluminal angioplasty [PTA] with stenting) has been increasingly applied in patients with chronic mesenteric ischemia (CMI) to avoid morbidities associated with open repair (OR). The purpose of this study was to compare outcomes of PTA/Stent vs OR in patients with symptomatic CMI. METHODS: During the interval of January 1991 to December 2005, 80 consecutive patients presenting with symptomatic CMI underwent elective revascularization. Patients with acute mesenteric ischemia or those with mesenteric revascularization performed as part of complex aneurysm repair were excluded. PTA/Stent (with stenting in 87%) was the initial procedure in 31 patients (42 vessels). OR was performed in 49 patients (88 vessels) and consisted of bypass grafting in 31 (63%), transaortic endarterectomy in 7 (14%), patch angioplasty in 4 (8%), or combined in 7 (15%). Mean follow-up was 15 months in the PTA/Stent group and 42 months in the OR cohort. Study end points included perioperative morbidity, mortality, late survival (Kaplan-Meier), and symptomatic and radiographic recurrence. RESULTS: Baseline comorbidities, with the exception of heart disease (P=.025) and serum albumin<3.5 g/dL (P=.025), were similar between PTA/Stent and OR patients. The PTA/Stent group had fewer vessels revascularized (1.5 vs 1.8 vessels, P=.001). Hospital length of stay was less for the PTA/Stent group (5.6 vs 16.7 days, P=.001). No difference was noted in in-hospital major morbidity (4/31 vs 2/49, P=.23) or mortality (1/31 vs 1/49, P=.74). Actuarial survival at 2 years was similar between the groups (88% PTA/Stent vs 74% OR, P=.28). There was no difference in the incidence of symptomatic (7/31 [23%] vs 11/49 [22%], P=.98) or radiographic recurrence (10/31 [32%] vs 18/49 [37%], P=.40) between the two groups. Radiographic primary patency (58% vs 90%, P=.001) and primary assisted patency (65% vs 96%, P<.001) at 1 year were lower in the PTA/Stent group compared with OR. Five (16%) of 31 PTA/Stent patients compared with 11 (22%) of 49 OR patients required a second intervention on at least one index vessel at any time (P=.49). CONCLUSIONS: Symptomatic recurrence requiring reintervention is common (overall 16/80 [20%]) after open and endovascular treatment for CMI. PTA/Stent was associated with decreased primary patency, primary assisted patency, and the need for earlier reintervention. In-hospital mortality or major morbidity were similar in patients undergoing PTA/Stent and OR. These findings suggest that OR and PTA/Stent should be applied selectively in CMI patients in accordance with individual patient anatomic and comorbidity considerations.     

Predicting outcome and directing therapy for papillary thyroid carcinoma

HYPOTHESIS: The prognosis of papillary thyroid carcinoma has been stratified into low- and high-risk groups. Patients in the high-risk group can be substratified on the basis of increasing age, with implications for prognosis and treatment. DESIGN: Retrospective study. SETTING: Tertiary care center. PATIENTS: A total of 727 patients with papillary thyroid cancer treated at Lahey Clinic, Burlington, Mass, from 1940 to 1998. INTERVENTIONS: Stratification into low- and high-risk groups based on age, metastases, extent, and size. High-risk patients were substratified into "younger" and "older" high-risk groups by age younger than 60 years or 60 years and older, respectively. Effects of surgery, lymph node dissection, and radiation therapy were examined.Main Outcome Measure Survival. RESULTS: Of the 727 patients, 585 (80.5%) were classified as low risk and 142 (19.5%) as high risk. The 20-year survival was 97.8% in low-risk patients and 61.3% in high-risk patients (P<.001); it was 72.3% in the younger high-risk group and 45.1% in the older high-risk group (P<.001). Older high-risk patients had a survival advantage with bilateral thyroidectomy: 54.7% 20-year survival for those undergoing bilateral thyroidectomy and 25.0% for unilateral thyroidectomy (P =.004). In the older high-risk group, patients with lymph node dissection (n = 22) had a 20-year survival of 72.4% vs 30.2% in patients who did not undergo lymph node dissection (n = 38) (P =.03). Twenty-year survival in low-risk, younger high-risk, and older high-risk patients receiving radioactive iodine vs no radiation was 100% vs 97.6% (P =.24), 64.2% vs 73.2% (P =.53), and 44.7% vs 44.4% (P =.53). CONCLUSIONS: Papillary thyroid carcinoma in low-risk patients had a favorable prognosis regardless of treatment. Older high-risk patients had a survival benefit with total thyroidectomy and lymph node dissection. Radioactive iodine did not affect 20-year survival in any of the risk groups.     

Re-Evaluation of Histopathological Factors Affecting Prognosis of Differentiated Thyroid Carcinoma in an Iodine-Sufficient Country

Background  

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.     

Insular carcinomas of the thyroid exhibit poor prognosis and long-term survival in comparison to follicular and papillary T4 carcinomas

Background Insular thyroid carcinoma was described as a tumor with aggressive behavior, and patients usually present themselves with an advanced tumor stage. Whether the insular component is an independent factor for poor prognosis remains unclear. Therefore, in the present study, we compared the survival of patients with advanced insular, follicular, and papillary thyroid cancer. Materials and methods The clinical behavior of tumors in three groups of patients with T4 thyroid carcinoma—8 patients with insular, 11 patients with follicular, and 21 patients with papillary thyroid carcinomas—was compared. Disease-free survival and disease-specific death were analyzed statistically. Cox regression analysis was used to evaluate the influence of histotype and other prognostic factors. Results At 3 years, survival was 37.5% (mean 26 months) among patients with insular thyroid carcinoma, 80% (mean 59 months) among those with follicular, and 89% (mean 126 months) among those with papillary thyroid carcinomas (p = 0.007). Disease-free survival in patients without initial distant metastasis was worst in patients with insular thyroid carcinoma (20%) compared to those with follicular (75%) and those with papillary thyroid carcinomas (71%). Conclusion Patients with advanced insular thyroid carcinoma have a poorer outcome in comparison to patients with similar advanced stage who have follicular or papillary thyroid carcinoma.     

Hürthle cell (oxyphilic) papillary thyroid carcinoma: a variant with more aggressive biologic behavior.

The latest World Health Organization International Classification defines papillary thyroid carcinoma by its "follicular cell differentiation...as well as characteristic nuclear changes". However the oxyphilic (Hürthle cell) papillary carcinoma have nuclei which generally resemble the nuclei seen in oxyphilic follicular carcinomas, and such oxyphilic papillary tumors may behave more aggressively than typical papillary cancers. To further characterize these rare tumors, we identified during a 32-year period 22 patients with oxyphilic papillary cancer and compared them with 1,084 patients with typical papillary cancers and 57 patients with oxyphilic follicular cancers treated by the Mayo surgical group during the same time period. Although typical papillary and oxyphilic papillary cancers were comparable with regards to patient age, tumor size and extent, TNM stage, and prognostic score (AGES), there were significant differences. Compared to typical papillary tumors, oxyphilic papillary cancers had fewer neck nodal metastases at primary diagnosis (5% vs 40%, p less than 0.0001), were more often DNA non-diploid (71% vs 21%, p less than 0.001), and after 10 postoperative years had higher rates of both tumor recurrence (28% vs 11%, p less than 0.0001) and cause-specific mortality (1.7% vs 4%, p less than 0.0005). In these four important respects the oxyphilic papillary cancers more resembled the oxyphilic follicular cancers. For oxyphilic follicular cancers, the frequency of initial neck nodal metastases was 7% (cf 5%); 83% of the oxyphilic follicular tumors were non-diploid (cf 71%), and at 10 years postoperatively the tumor recurrence and cause-specific mortality rates were 28% and 18%, insignificantly different from 28% and 17% seen with the oxyphilic papillary cancers.(ABSTRACT TRUNCATED AT 250 WORDS)