scholarly journals The diagnostic function of intravoxel incoherent motion for distinguishing between pilocytic astrocytoma and ependymoma

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0247899
Author(s):  
Nguyen Minh Duc
Keyword(s):  
Roc Curve ◽  
Pilocytic Astrocytoma ◽  
Diagnostic Performance ◽  
Exponential Model ◽  
Curve Analysis ◽  
Intravoxel Incoherent Motion ◽  
Contrast Imaging ◽  
Roc Curve Analysis ◽  
D Values ◽  
D Value

Introduction Intravoxel incoherent motion (IVIM) imaging concurrently measures diffusion and perfusion parameters and has potential applications for brain tumor classification. However, the effectiveness of IVIM for the differentiation between pilocytic astrocytoma and ependymoma has not been verified. The aim of this study was to determine the potential diagnostic role of IVIM for the distinction between ependymoma and pilocytic astrocytoma. Methods Between February 2019 and October 2020, 22 children (15 males and 7 females; median age 4 years) with either ependymoma or pilocytic astrocytoma were recruited for this prospective study. IVIM parameters were fitted using 7 b-values (0–1,500 s/mm2), to develop a bi-exponential model. The diffusivity (D), perfusion fraction (f), and pseudo diffusivity (D*) were measured in both tumors and the adjacent normal-appearing parenchyma. These IVIM parameters were compared using the Mann-Whitney U test. Receiver operating characteristic (ROC) curve analysis was employed to assess diagnostic performance. Results The median D values for ependymoma and pilocytic astrocytoma were 0.87 and 1.25 × 10−3 mm2/s (p < 0.05), respectively, whereas the f values were 0.11% and 0.15% (p < 0.05). The ratios of the median D values for ependymoma and pilocytic astrocytoma relative to the median D values for the adjacent, normal-appearing parenchyma were 1.45 and 2.10 (p < 0.05), respectively. ROC curve analysis found that the D value had the best diagnostic performance for the differentiation between pilocytic astrocytoma and ependymoma, with an area under the ROC curve of 1. Conclusion IVIM is a beneficial, effective, non-invasive, and endogenous-contrast imaging technique. The D value derived from IVIM was the most essential factor for differentiating ependymoma from pilocytic astrocytoma.

scholarly journals Erythrocyte and Reticulocyte Indices on the LH 750 as Potential Markers of Functional Iron Deficiency

Anemia ◽  
2010 ◽  
Vol 2010 ◽  
pp. 1-7 ◽  
Author(s):  
Eloísa Urrechaga ◽  
Luís Borque ◽  
Jesús F. Escanero
Keyword(s):  
Iron Deficiency ◽  
Roc Curve ◽  
Diagnostic Performance ◽  
Iron Status ◽  
Curve Analysis ◽  
Size Factor ◽  
Hemoglobin Content ◽  
Roc Curve Analysis ◽  
Functional Iron Deficiency ◽  
Reticulocyte Hemoglobin Content

Reticulocyte hemoglobin content (CHr) and percentage of hypochromic cells (%Hypo) are restricted to the Siemens analysers. The aims of the study were to investigate the correlation of Red cells size factor (RSf) and low Hemoglobin density (LHD%), reported by Beckman-Coulter analysers, with CHr and %Hypo in the assessment of iron status in the presence of inflammation. 381 samples were run on both LH 750 (Beckman-Coulter) and Advia 2120 (Siemens) analysers. Correlation between parameters were calculated and the diagnostic performance of the new parameters was assessed.Results. Correlation between RSf and CHr, . ROC curve analysis for RSf in the diagnosis of iron restricted erythropoiesis defined as CH pg: AUC 0.983; Cutoff 91.1%; Sensitivity 98.8%; Specificity 89.6% Correlation between LHD% and %Hypo, . ROC curve analysis for LHD% in the diagnosis of iron deficiency defined by %Hypo %: AUC 0.954; Cut off 6.0%; Sensitivity 96.6%; Specificity 83.2%Conclusions. RSf and LHD% could be reliable parameters for the study of iron metabolism status.

scholarly journals Evaluation of serum AFP and DCP levels in the diagnosis of early-stage HBV-related HCC under different backgrounds

2020 ◽  
Vol 48 (10) ◽  
pp. 030006052096908
Author(s):  
Ting Song ◽  
Lili Wang ◽  
Ruopei Xin ◽  
Liping Zhang ◽  
Yun Tian
Keyword(s):  
Roc Curve ◽  
Diagnostic Performance ◽  
Operating Characteristic ◽  
Early Stage ◽  
Area Under The Curve ◽  
Curve Analysis ◽  
Roc Curve Analysis ◽  
Chronic Hbv Infection ◽  
B Virus ◽  
Chronic Hbv

Objective This study compared the diagnostic performance of alpha-fetoprotein (AFP) and des-gamma-carboxyprothrombin (DCP) in early-stage hepatitis B virus-related hepatocellular carcinoma (HBV-HCC) under different backgrounds. Methods Patients were enrolled and divided in four groups: chronic HBV infection (CHB), liver cirrhosis (LC), early-stage CHB-HCC, and early-stage LC-HCC. Serum AFP and DCP levels were measured. Receiver-operating characteristic (ROC) curve and area under the curve (AUC) analyses were applied to compare the diagnostic performance of DCP and AFP for HCC. Results In total, 200 patients were enrolled, including 48, 64, 33, and 55 patients with CHB, LC, CHB-HCC, and LC-HCC, respectively. ROC curve analysis revealed that the AUCs of AFP, DCP, and their combination in differentiating early-stage LC-HCC from LC were 0.776, 0.758, and 0.786, respectively. The values of these markers in discriminating early-stage CHB-HCC from CHB were 0.828, 0.731, and 0.862, respectively. Conclusions DCP was inferior to AFP in differentiating early-stage CHB-HCC from CHB. However, AFP and DCP displayed similar performance in distinguishing early-stage LC-HCC and LC.

scholarly journals Diagnostic performance of total-body 18F-FDG PET/CT with fast 2-min acquisition for liver tumours: Comparison with conventional PET/CT

2021 ◽  
Author(s):  
Yan Hu ◽  
Guobing Liu ◽  
Haojun Yu ◽  
Jianying Gu ◽  
Hongcheng Shi
Keyword(s):  
Liver Cancer ◽  
Cancer Patients ◽  
Roc Curve ◽  
Diagnostic Performance ◽  
Curve Analysis ◽  
Roc Curve Analysis ◽  
Liver Tumours ◽  
Pet Ct ◽  
Total Body ◽  
Fdg Pet Ct

Abstract PurposeTo comparatively evaluate the diagnostic performances of total-body 18F-FDG PET/CT with fast 2-min acquisition and conventional PET/CT in liver cancer patients.Methods This study included 156 patients with liver tumours. Seventy-eight patients underwent total-body PET/CT. PET raw data were reconstructed using acquisition durations of 2 min (G2) and 15 min (G15). Another 78 patients with liver lesions (control patients) underwent conventional uMI780 PET/CT (G780). All patients were evaluated based on TNM staging. The maximum tumour standardized uptake value (tumour SUVmax), mean normal liver SUV (SUVmean), and tumour SUVmax-to-liver SUVmean ratio (TLR) were determined for all patients. G15 data were used as the reference in the lesion detectability analysis. The diagnostic performances of PET/CT in terms of visual parameters and of PET in terms of semi-quantitative parameters such as SUVmax and TLR were evaluated. Receiver operating characteristics (ROC) curve analysis of SUVmax and TLR at G2 was performed. Pathologic findings of surgical specimens served as the gold standard for all patients.Results The lesions found in G15 were also noted in G2; three lymph nodes were missed in G2; however, no significant difference was found in the TNM stage among G2, G15, and G780. For benign and malignant lesions, the liver SUVmean in G2 and G15 was higher than that in G780 (all P < 0.05). The tumour SUVmax and TLR in G2 were equivalent to those in G15 and G780 regardless of whether the lesions were benign or malignant. ROC curve analysis (SUVmax cut-off: 4.34, TLR cut-off: 1.34) demonstrated that G2 also had good sensitivity in detecting liver cancer. Conclusion The diagnostic performance of total-body PET/CT in G2 was comparable to that in G15 among liver cancer patients. Further, the diagnostic efficiency of total-body PET/CT imaging with fast 2-min acquisition and conventional PET/CT was similar.

Acute heart failure: predicting early in-hospital outcomes

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
M Santos ◽  
S Paula ◽  
I Almeida ◽  
H Santos ◽  
H Miranda ◽  
...  
Keyword(s):  
Heart Failure ◽  
Logistic Regression ◽  
Acute Heart Failure ◽  
Roc Curve ◽  
Real Life ◽  
Study Data ◽  
Curve Analysis ◽  
Older Age ◽  
Invasive Ventilation ◽  
Roc Curve Analysis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients (P) with acute heart failure (AHF) are a heterogeneous population. Risk stratification at admission may help predict in-hospital complications and needs. The Get With The Guidelines Heart Failure score (GWTG-HF) predicts in-hospital mortality (M) of P admitted with AHF. ACTION ICU score is validated to estimate the risk of complications requiring ICU care in non-ST elevation acute coronary syndromes. Objective To validate ACTION-ICU score in AHF and to compare ACTION-ICU to GWTG-HF as predictors of in-hospital M (IHM), early M [1-month mortality (1mM)] and 1-month readmission (1mRA), using real-life data. Methods Based on a single-center retrospective study, data collected from P admitted in the Cardiology department with AHF between 2010 and 2017. P without data on previous cardiovascular history or uncompleted clinical data were excluded. Statistical analysis used chi-square, non-parametric tests, logistic regression analysis and ROC curve analysis. Results Among the 300 P admitted with AHF included, mean age was 67.4 ± 12.6 years old and 72.7% were male. Systolic blood pressure (SBP) was 131.2 ± 37.0mmHg, glomerular filtration rate (GFR) was 57.1 ± 23.5ml/min. 35.3% were admitted in Killip-Kimball class (KKC) 4. ACTION-ICU score was 10.4 ± 2.3 and GWTG-HF was 41.7 ± 9.6. Inotropes’ usage was necessary in 32.7% of the P, 11.3% of the P needed non-invasive ventilation (NIV), 8% needed invasive ventilation (IV). IHM rate was 5% and 1mM was 8%. 6.3% of the P were readmitted 1 month after discharge. Older age (p &lt; 0.001), lower SBP (p = 0,035) and need of inotropes (p &lt; 0.001) were predictors of IHM in our population. As expected, patients presenting in KKC 4 had higher IHM (OR 8.13, p &lt; 0.001). Older age (OR 1.06, p = 0.002, CI 1.02-1.10), lower SBP (OR 1.01, p = 0.05, CI 1.00-1.02) and lower left ventricle ejection fraction (LVEF) (OR 1.06, p &lt; 0.001, CI 1.03-1.09) were predictors of need of NIV. None of the variables were predictive of IV. LVEF (OR 0.924, p &lt; 0.001, CI 0.899-0.949), lower SBP (OR 0.80, p &lt; 0.001, CI 0.971-0.988), higher urea (OR 1.01, p &lt; 0.001, CI 1.005-1.018) and lower sodium (OR 0.92, p = 0.002, CI 0.873-0.971) were predictors of inotropes’ usage. Logistic regression showed that GWTG-HF predicted IHM (OR 1.12, p &lt; 0.001, CI 1.05-1.19), 1mM (OR 1.10, p = 1.10, CI 1.04-1.16) and inotropes’s usage (OR 1.06, p &lt; 0.001, CI 1.03-1.10), however it was not predictive of 1mRA, need of IV or NIV. Similarly, ACTION-ICU predicted IHM (OR 1.51, p = 0.02, CI 1.158-1.977), 1mM (OR 1.45, p = 0.002, CI 1.15-1.81) and inotropes’ usage (OR 1.22, p = 0.002, CI 1.08-1.39), but not 1mRA, the need of IV or NIV. ROC curve analysis revealed that GWTG-HF score performed better than ACTION-ICU regarding IHM (AUC 0.774, CI 0.46-0-90 vs AUC 0.731, CI 0.59-0.88) and 1mM (AUC 0.727, CI 0.60-0.85 vs AUC 0.707, CI 0.58-0.84). Conclusion In our population, both scores were able to predict IHM, 1mM and inotropes’s usage.

scholarly journals Presepsin values and prognostic nutritional index predict mortality in intensive care unit patients with sepsis: a pilot study

2021 ◽  
Vol 14 (1) ◽  
Author(s):  
Yuichiro Shimoyama ◽  
Osamu Umegaki ◽  
Noriko Kadono ◽  
Toshiaki Minami
Keyword(s):  
Multivariate Analysis ◽  
Roc Curve ◽  
Operating Characteristic ◽  
Prognostic Nutritional Index ◽  
Early Mortality ◽  
Curve Analysis ◽  
Rank Test ◽  
Roc Curve Analysis ◽  
Log Rank Test ◽  
Nutritional Index

Abstract Objective Sepsis is a major cause of mortality for critically ill patients. This study aimed to determine whether presepsin values can predict mortality in patients with sepsis. Results Receiver operating characteristic (ROC) curve analysis, Log-rank test, and multivariate analysis identified presepsin values and Prognostic Nutritional Index as predictors of mortality in sepsis patients. Presepsin value on Day 1 was a predictor of early mortality, i.e., death within 7 days of ICU admission; ROC curve analysis revealed an AUC of 0.84, sensitivity of 89%, and specificity of 77%; and multivariate analysis showed an OR of 1.0007, with a 95%CI of 1.0001–1.0013 (p = 0.0320).

scholarly journals Soluble cytotoxic T-lymphocyte–associated antigen 4 (sCTLA-4) as a potential biomarker for diagnosis and evaluation of the prognosis in Glioma

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Jiajia Liu ◽  
Xiaoyi Tian ◽  
Yan Wang ◽  
Xixiong Kang ◽  
Wenqi Song
Keyword(s):  
T Lymphocyte ◽  
Roc Curve ◽  
Cytotoxic T Lymphocyte ◽  
Tumor Grade ◽  
Curve Analysis ◽  
Enzyme Linked Immunosorbent Assay ◽  
Low Grade ◽  
High Grade ◽  
Healthy Individuals ◽  
Roc Curve Analysis

Abstract Background The cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) is widely considered as a pivotal immune checkpoint molecule to suppress antitumor immunity. However, the significance of soluble CTLA-4 (sCTLA-4) remains unclear in the patients with brain glioma. Here we aimed to investigate the significance of serum sCTLA-4 levels as a noninvasive biomarker for diagnosis and evaluation of the prognosis in glioma patients. Methods In this study, the levels of sCTLA-4 in serum from 50 patients diagnosed with different grade gliomas including preoperative and postoperative, and 50 healthy individuals were measured by an enzyme-linked immunosorbent assay (ELISA). And then ROC curve analysis and survival analyses were performed to explore the clinical significance of sCTLA-4. Results Serum sCTLA-4 levels were significantly increased in patients with glioma compared to that of healthy individuals, and which was also positively correlated with the tumor grade. ROC curve analysis showed that the best cutoff value for sCTLA-4 for glioma is 112.1 pg/ml, as well as the sensitivity and specificity with 82.0 and 78.0%, respectively, and a cut-off value of 220.43 pg/ml was best distinguished in patients between low-grade glioma group and high-grade glioma group with sensitivity 73.1% and specificity 79.2%. Survival analysis revealed that the patients with high sCTLA-4 levels (> 189.64 pg/ml) had shorter progression-free survival (PFS) compared to those with low sCTLA-4 levels (≤189.64 pg/ml). In the univariate analysis, elder, high-grade tumor, high sCTLA-4 levels and high Ki-67 index were significantly associated with shorter PFS. In the multivariate analysis, sCTLA-4 levels and tumor grade remained an independent prognostic factor. Conclusion These findings indicated that serum sCTLA-4 levels play a critical role in the pathogenesis and development of glioma, which might become a valuable predictive biomarker for supplementary diagnosis and evaluation of the progress and prognosis in glioma.

scholarly journals Predictive CT features for the diagnosis of primary pulmonary mucoepidermoid carcinoma: comparison with squamous cell carcinomas and adenocarcinomas

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Xiaohua Ban ◽  
Xinping Shen ◽  
Huijun Hu ◽  
Rong Zhang ◽  
Chuanmiao Xie ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Roc Curve ◽  
Multinomial Logistic Regression ◽  
Univariate Analysis ◽  
Ct Imaging ◽  
Squamous Cell Carcinomas ◽  
Curve Analysis ◽  
Imaging Features ◽  
Roc Curve Analysis ◽  
Ct Features

Abstract Background To determine the predictive CT imaging features for diagnosis in patients with primary pulmonary mucoepidermoid carcinomas (PMECs). Materials and methods CT imaging features of 37 patients with primary PMECs, 76 with squamous cell carcinomas (SCCs) and 78 with adenocarcinomas were retrospectively reviewed. The difference of CT features among the PMECs, SCCs and adenocarcinomas was analyzed using univariate analysis, followed by multinomial logistic regression and receiver operating characteristic (ROC) curve analysis. Results CT imaging features including tumor size, location, margin, shape, necrosis and degree of enhancement were significant different among the PMECs, SCCs and adenocarcinomas, as determined by univariate analysis (P < 0.05). Only lesion location, shape, margin and degree of enhancement remained independent factors in multinomial logistic regression analysis. ROC curve analysis showed that the area under curve of the obtained multinomial logistic regression model was 0.805 (95%CI: 0.704–0.906). Conclusion The prediction model derived from location, margin, shape and degree of enhancement can be used for preoperative diagnosis of PMECs.

scholarly journals Mortality risk prediction in lupus patients complicated with invasive infection in the emergency department: LUPHAS score

2019 ◽  
Vol 11 ◽  
pp. 1759720X1988555 ◽  
Author(s):  
Wanlong Wu ◽  
Jun Ma ◽  
Yuhong Zhou ◽  
Chao Tang ◽  
Feng Zhao ◽  
...  
Keyword(s):  
Emergency Department ◽  
Prediction Model ◽  
Risk Score ◽  
Roc Curve ◽  
Curve Analysis ◽  
Multivariable Logistic Regression Analysis ◽  
Invasive Infection ◽  
Roc Curve Analysis ◽  
All Cause Mortality ◽  
Qsofa Score

Background: Infection remains a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). This study aimed to establish a clinical prediction model for the 3-month all-cause mortality of invasive infection events in patients with SLE in the emergency department. Methods: SLE patients complicated with invasive infection admitted into the emergency department were included in this study. Patient’s demographic, clinical, and laboratory characteristics on admission were retrospectively collected as baseline data and compared between the deceased and the survivors. Independent predictors were identified by multivariable logistic regression analysis. A prediction model for all-cause mortality was established and evaluated by receiver operating characteristic (ROC) curve analysis. Results: A total of 130 eligible patients were collected with a cumulative 38.5% 3-month mortality. Lymphocyte count <800/ul, urea >7.6mmol/l, maximum prednisone dose in the past ⩾60 mg/d, quick Sequential Organ Failure Assessment (qSOFA) score, and age at baseline were independent predictors for all-cause mortality (LUPHAS). In contrast, a history of hydroxychloroquine use was protective. In a combined, odds ratio-weighted LUPHAS scoring system (score 3–22), patients were categorized to three groups: low-risk (score 3–9), medium-risk (score 10–15), and high-risk (score 16–22), with mortalities of 4.9% (2/41), 45.9% (28/61), and 78.3% (18/23) respectively. ROC curve analysis indicated that a LUPHAS score could effectively predict all-cause mortality [area under the curve (AUC) = 0.86, CI 95% 0.79–0.92]. In addition, LUPHAS score performed better than the qSOFA score alone (AUC = 0.69, CI 95% 0.59–0.78), or CURB-65 score (AUC = 0.69, CI 95% 0.59–0.80) in the subgroup of lung infections ( n = 108). Conclusions: Based on a large emergency cohort of lupus patients complicated with invasive infection, the LUPHAS score was established to predict the short-term all-cause mortality, which could be a promising applicable tool for risk stratification in clinical practice.

scholarly journals Right choice of a method for determination of cut-off values: A statistical tool for a diagnostic test

2014 ◽  
Vol 5 (3) ◽  
pp. 30-34 ◽  
Author(s):  
Balkishan Sharma ◽  
Ravikant Jain
Keyword(s):  
Logistic Regression ◽  
Discriminant Analysis ◽  
Diagnostic Test ◽  
Roc Curve ◽  
Traditional Method ◽  
Statistical Technique ◽  
Curve Analysis ◽  
Operating Characteristics ◽  
Roc Curve Analysis

Objective: The clinical diagnostic tests are generally used to identify the presence of a disease. The cutoff value of a diagnostic test should be chosen to maximize the advantage that accrues from testing a population of human and others. When a diagnostic test is to be used in a clinical condition, there may be an opportunity to improve the test by changing the cutoff value. To enhance the accuracy of diagnosis is to develop new tests by using a proper statistical technique with optimum sensitivity and specificity. Method: Mean±2SD method, Logistic Regression Analysis, Receivers Operating Characteristics (ROC) curve analysis and Discriminant Analysis (DA) have been discussed with their respective applications. Results: The study highlighted some important methods to determine the cutoff points for a diagnostic test. The traditional method is to identify the cut-off values is Mean±2SD method. Logistic Regression Analysis, Receivers Operating Characteristics (ROC) curve analysis and Discriminant Analysis (DA) have been proved to be beneficial statistical tools for determination of cut-off points.Conclusion: There may be an opportunity to improve the test by changing the cut-off value with the help of a correctly identified statistical technique in a clinical condition when a diagnostic test is to be used. The traditional method is to identify the cut-off values is Mean ± 2SD method. It was evidenced in certain conditions that logistic regression is found to be a good predictor and the validity of the same can be confirmed by identifying the area under the ROC curve. Abbreviations: ROC-Receiver operating characteristics and DA-Discriminant Analysis. Asian Journal of Medical Science, Volume-5(3) 2014: 30-34 http://dx.doi.org/10.3126/ajms.v5i3.9296      

Assessment of Biomarkers for Clinical Diagnosis of Papillary Thyroid Carcinoma with Distant Metastasis

2010 ◽  
Vol 25 (1) ◽  
pp. 38-45 ◽  
Author(s):  
Huasheng Liang ◽  
Yuhua Zhong ◽  
Zuojie Luo ◽  
Yu Huang ◽  
Huade Lin ◽  
...  
Keyword(s):  
Growth Factor ◽  
Papillary Thyroid Carcinoma ◽  
Thyroid Carcinoma ◽  
Clinical Diagnosis ◽  
Distant Metastasis ◽  
Roc Curve ◽  
Curve Analysis ◽  
Papillary Thyroid ◽  
Roc Curve Analysis ◽  
Thyroid Carcinomas

Early diagnosis and treatment of thyroid cancers are critical for better prognosis and better survival rates. The purpose of this study was to identify potential diagnostic markers for papillary thyroid carcinomas with distant metastasis. Fifty-eight papillary thyroid tumor specimens (27 papillary thyroid carcinomas with distant metastasis and 31 without metastasis) were examined, and protein expression of pituitary tumor-transforming gene (PTTG), E-cadherin, p27kip1, vascular endothelial growth factor (VEGF)-C, metalloproteinase (MMP) 2, MMP9, chemokine receptor CXCR4, and basic fibroblast growth factor (bFGF) in these tumors was assessed by immunohistochemistry. The clinicopathological variables with diagnostic significance were determined by multivariate analysis, and their diagnostic values were evaluated by ROC curve analysis. PTTG, VEGF-C, MMP2, MMP9, CXCR4, and bFGF were overexpressed in metastatic papillary thyroid carcinomas, whereas p27kip1 expression was elevated only in carcinomas lacking metastasis. Multiple-factor binary ordinal logistic regression analysis revealed that PTTG, VEGF-C, MMP2, and bFGF were independently related to biological metastatic behavior in thyroid tumors, suggesting their potential use as biomarkers. ROC curve analysis showed that among these four proteins, VEGF-C and bFGF were the best diagnostic biomarkers. A VEGF-C and bFGF cluster was the most useful factor for the differential diagnosis between metastatic and non-metastatic papillary thyroid cancers. Thus, the combined use of VEGF-C and bFGF as biomarkers may improve the diagnostic accuracy of papillary thyroid carcinoma and may be useful in multimodal screening programs for the clinical diagnosis of papillary thyroid carcinoma and early detection of papillary thyroid carcinoma with distant metastasis.

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