Jeremy L. Freeman

The purpose of this study was to demonstrate the utility of a personalized risk stratification and radioactive iodine (RAI) selection protocol (PRSP) using post-operative stimulated thyroglobulin (Stim-Tg) and neck ultrasound in low- and intermediate-risk papillary thyroid carcinoma (PTC) patients. Patients with PTC tumors ≥1 cm were prospectively followed after total thyroidectomy and selective therapeutic central compartment neck dissection. Low/intermediate risk was defined as PTC confined to the thyroid or central (level VI) lymph nodes. Stim-Tg and neck ultrasound were performed approximately 3 months after surgery and used to guide RAI selection. Patients with Stim-Tg < 1 µg/L did not receive RAI, while those with Stim-Tg >5 µg/L routinely did. Those with Stim-Tg 1–5 µg/L received RAI on the basis of several clinical risk factors. Patients were followed for >6 years with serial neck ultrasound and basal/stimulated thyroglobulin. Among the 129 patients, 84 (65 %) had undetectable Stim-Tg after initial surgery, 40 (31 %) had Stim-Tg of 1–5 µg/L, and 5 (4 %) had Stim-Tg >5 µg/L. RAI was administered to 8 (20 %) patients with Stim-Tg 1–5 µg/L and 5 (100 %) with Stim-Tg >5 µg/L. Using this approach, RAI therapy was avoided in 17/20 (85 %) patients with tumors >4 cm, in 72/81 (89 %) patients older than 45 years, and in 6/9 (67 %) patients with central lymph node involvement. To date, 116 (90 %) patients in this cohort have not received RAI therapy with no evidence of residual/recurrent disease, whereas among the 13 patients who received RAI, 1 (8 %) had pathologic residual/recurrence disease. Using the proposed PRSP, RAI can be avoided in the majority of low/intermediate-risk PTC patients. Moreover, traditional risk factors considered to favor RAI treatment were not always concordant with the PRSP and may lead to overtreatment.

The second World Congress on Thyroid Cancer was held from July 10 to July 14, 2013, in Toronto, Canada. Its purpose was to provide a platform for the multidisciplinary discussion on research, education, and patient management of thyroid malignancy. Herein, we summarize the latest major trends and controversies within the field of thyroid oncology as discussed in the Congress including the use of ultrasound, standardization of cytology, role of molecular testing, treatment options for small recurrence including ablation and observation, management of recurrent laryngeal nerve injury, importance of identification of the external branch of the superior laryngeal nerve, role of minimally invasive thyroid surgery, trends in radioactive iodine treatment, advancements in targeted agents, and the importance of personalizing treatment to individual patients. © 2014 Wiley Periodicals, Inc. Head Neck 36: 917–920, 2014

Background: The primary objective of this study is to describe variations in incidence rates, resection rates, and types of surgical ablations performed on patients diagnosed with major salivary gland cancers in Ontario. Methods: All major salivary gland cancer cases in Ontario (2003–2010) were identified from the Ontario Cancer Registry (n = 1,241). Variations in incidence rates, resection rates, and type of surgical therapy were compared by sex, age group, neighbourhood income, community population, health region, and physician specialty. Results: Eight-year incidence rates per 100,000 vary significantly by sex (male: 15.5, female: 9.7), age (18–54 years: 6.7, 75+ years: 53.4), neighborhood income (lowest quintile: 11.8, highest quintile: 13.7), and community size (cities with a population greater than 1.5 million: 10.6, cities with a population of less than 100,000: 14.7). There was a significant correlation between the likelihood to receive a resection and age with the elderly (75+ years) being the least likely to receive resection (69%). Large differences in incidence and resection rates were observed by health region. Otolaryngology-Head & Neck surgeons provide the majority of total/radical resections (95%). Conclusions: Major salivary gland cancer incidence rates vary by sex, age, neighborhood income, community size, and health region. Resection rates vary by age and health region. These disparities warrant further evaluation. Otolaryngology-Head & Neck Surgeons provide the majority of major salivary gland cancer surgical care.

Introduction: The detection of papillary thyroid microcarcinoma (PTMC) is on the rise and its optimal management remains controversial. Our aim was to determine the current self-reported management of PTMC amongst Canadian otolaryngologist-head and neck surgeons (OHNS) and endocrinologists and to identify factors influencing their management decisions. Methods: A nine item web-based questionnaire was distributed to Canadian OHNS and endocrinologists. The three main domains were demographics, current management of PTMC scenarios, and factors influencing the decisions. Results: One hundred and thirteen OHNS and endocrinologists completed the survey. Respondents were closely divided between recommending hemithyroidectomy (47%) or total thyroidectomy (43%) for a newly diagnosed PTMC in a low risk patient. Observation was the preferred method for managing PTMC detected incidentally after hemithyroidectomy (76%). Respondents chose more aggressive treatment for male patients compared to female patients. A positive history of thyroid cancer or previous radiation exposure was the most important factor influencing the management of PTMC. Conclusion: The current practices of Canadian OHNS and endocrinologist largely coincide with available guidelines. The slight variation in practice might be explained by the opposing evidence supporting different management options. Given the dramatic increase in the incidence of PTMC we suggest future guidelines address the management of PTMC independently.

Objective To identify additional preoperative factors that could reliably be used to aid in determining the appropriate extent of thyroidectomy. Design Retrospective chart review. Setting Tertiary care academic hospital. Patients Two hundred consecutively treated patients who underwent thyroid surgery after having a fine-needle aspiration biopsy procedure yielding a specimen that met the criteria for atypical cytologic features. Main Outcome Measure Final histopathologic diagnosis of malignant vs benign disease. Results The final diagnosis was benign in 42.5% of patients and malignant in 57.5%. The presence of microcalcifications within the nodule on ultrasonography (US) was significantly associated with a higher risk of malignant disease (relative risk = 1.31, P = .04). When examined individually, age, sex, family history of thyroid malignant disease, exposure to head and neck irradiation, nodule size, rim enhancement on US, and intranodular vascularity on US were not significantly associated with an increased risk of malignant disease. Mulivariate stepwise logistic regression modeling was used to identify a model that could reliably predict a higher probability of malignant disease. The final model determined that patients with microcalcifications on US and a nodule of 2.0 cm or larger had a 74.3% risk of malignant disease vs a 47.5% risk in patients with no microcalcifications and a nodule smaller than 2.0 cm. This difference was statistically significant. When the predicted probabilities of malignant disease were compared with the observed probabilities, the goodness-of-fit test revealed no significant difference (P = .95). Conclusion Microcalcifications and nodule size can be used to risk-stratify patients with an atypical fine-needle aspiration biopsy result and aid in determining the appropriate extent of thyroidectomy.

Proteolytic cleavage of the extracellular domain (EpEx) of Epithelial cell adhesion molecule (EpCAM) and nuclear signaling by its intracellular oncogenic domain Ep-ICD has recently been implicated in increased proliferation of cancer cells. The clinical significance of Ep-ICD in human tumors remains an enigma.

Thyroid cancer is generally considered an indolent disease with a favorable prognosis, as the most common subtypes are associated with long-term survival rates of more than 90%.¹ Nevertheless, at least 15% of patients experience disease recurrence² and are subject to morbidity from further cancer therapy. Therefore, an important focus of thyroid cancer research has been to identify factors that predispose patients to poor disease outcomes. Various prognostic factors have been identified, including age, sex, family history of thyroid cancer, tumor size and histologic grade, history of head and neck radiation exposure, extrathyroidal spread, presence of distant metastases, completeness of resection, advanced stage at presentation, aggressive histologic subtype, presence of tumor multifocality, vascular invasion, and certain genetic mutations.^3-9 Although patient race/ethnicity has been described as a prognostic factor for other forms of cancer,^10,11 few data exist regarding the effect of race/ethnicity on the outcomes of thyroid cancer.

Introduction.Patients with multiple recurrences of well-differentiated thyroid carcinoma (WDTC) have markedly reduced overall survival when compared with those who have 1 recurrence of their disease. The purpose of this investigation is to identify prognostic factors for mortality in this subgroup.Methods.Patients with multiple recurrences of WDTC were retrospectively identified from the thyroid cancer database at Mount Sinai Hospital, Toronto (1963–2000). Data on patient, tumor, and recurrence characteristics were collected, and each patient was given aMACIS score.Results.A total of 31 patients were identified (11 male, 20 female; 16–83 years). Using univariate analysis, age 45, stage disease, distant metastasis, vascular invasion, MACIS score 6, and time to recurrence of 12 months were found to be significant predictors for mortality in this subgroup.Conclusions.Patients with multiple recurrences of WDTC follow a distinct clinical course, marked with multiple treatment failures and a substantial risk of mortality.