scholarly journals Delayed risk stratification system in pT1aN0/Nx DTC patients treated without radioactive iodine

2017 ◽  
Vol 6 (7) ◽  
pp. 522-527 ◽  
Author(s):  
Danuta Gąsior-Perczak ◽  
Iwona Pałyga ◽  
Monika Szymonek ◽  
Artur Kowalik ◽  
Agnieszka Walczyk ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Clinical Outcomes ◽  
Radioactive Iodine ◽  
Initial Therapy ◽  
American Thyroid Association ◽  
Monitoring Method ◽  
Risk Patients ◽  
Structural Disease ◽  
Stratification System

Purpose Delayed risk stratification (DRS) system by Momesso and coworkers was accepted by the American Thyroid Association as a diagnostic tool for the risk stratification of unfavorable clinical outcomes and to monitor the clinical outcomes of differentiated thyroid cancer (DTC) patients treated without radioactive iodine (RAI). The aim of this study was to evaluate the DRS system in patients with pT1aN0/Nx stage. Methods The study included 304 low-risk patients after thyroidectomy (n = 202) or lobectomy (n = 102) without RAI and were treated at a single center. The median age was 50.5 years, 91.1% were women and the median follow-up was 4 years. DRS of the treatment response was performed based on medical records and according to the criteria of Momesso and coworkers. Disease course (recurrence, death) and status (remission, persistent disease) on December 31, 2016 were evaluated. The relationship between unfavorable outcomes and the DRS system was evaluated. Results Response to initial therapy was excellent in 272 patients (89.5%), indeterminate in 31 (10.2%) and biochemical incomplete (increased TgAb levels) in one (0.3%). Two patients in the excellent response group experienced recurrence at 6 and 7 years of follow-up (after lobectomy). None of the patients with indeterminate and biochemical incomplete response developed structural disease, and none of the patients died during the follow-up. Conclusions The DRS system was not useful for predicting the risk of unfavorable clinical outcomes and cannot be used to personalize the monitoring method of the disease in patients at pT1aN0/Nx stage who are not treated with RAI.

scholarly journals Evaluation of the 2015 ATA Guidelines in Patients With Distant Metastatic Differentiated Thyroid Cancer

2019 ◽  
Vol 105 (3) ◽  
pp. e457-e465
Author(s):  
Evert F S van Velsen ◽  
Merel T Stegenga ◽  
Folkert J van Kemenade ◽  
Boen L R Kam ◽  
Tessa M van Ginhoven ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
Differentiated Thyroid Cancer ◽  
Distant Metastases ◽  
Initial Therapy ◽  
Control Group ◽  
American Thyroid Association ◽  
Excellent Response ◽  
Structural Disease ◽  
Stratification System

Abstract Context Current American Thyroid Association (ATA) Management Guidelines for the treatment of differentiated thyroid cancer (DTC) stratify patients to decide on additional radioiodine (RAI) therapy after surgery, and to predict recurring/persisting disease. However, studies evaluating the detection of distant metastases and how these guidelines perform in patients with distant metastases are scarce. Objective To evaluate the 2015 ATA Guidelines in DTC patients with respect to 1) the detection of distant metastases, and 2) the accuracy of its Risk Stratification System in patients with distant metastases. Patients and Main Outcome Measures We retrospectively included 83 DTC patients who were diagnosed with distant metastases around the time of initial therapy, and a control population of 472 patients (312 low-risk, 160 intermediate-risk) who did not have a routine indication for RAI therapy. We used the control group to assess the percentage of distant metastases that would have been missed if no RAI therapy was given. Results Two hundred forty-six patients had no routine indication for RAI therapy of which 4 (1.6%) had distant metastases. Furthermore, among the 83 patients with distant metastases, 14 patients (17%) had excellent response, while 55 (67%) had structural disease after a median follow-up of 62 months. None of the 14 patients that achieved an excellent response had a recurrence. Conclusions In patients without a routine indication for RAI therapy according to the 2015 ATA Guidelines, distant metastases would initially have been missed in 1.6% of the patients. Furthermore, in patients with distant metastases upon diagnosis, the 2015 ATA Guidelines are an excellent predictor of both persistent disease and recurrence.

Shifting paradigms in the management of pediatric differentiated thyroid cancer from static to dynamic risk stratification: a step forward toward precision medicine

2019 ◽  
Vol 58 (03) ◽  
pp. 249-257
Author(s):  
Sadegh Ebrahim Ajdari ◽  
Babak Shafiei ◽  
Motahareh Motazedian ◽  
Mohsen Qutbi ◽  
Paridokht Esmaeilzadeh ◽  
...  
Keyword(s):  
High Risk ◽  
Pediatric Patients ◽  
Initial Therapy ◽  
High Risk Patients ◽  
Dynamic Risk ◽  
Radioiodine Ablation ◽  
Risk Patients ◽  
Structural Disease ◽  
Response Group

Abstract Introduction This study aimed to assess the usefulness of a risk-adopted management system known as dynamic risk stratification (DRS) in comparison with the American (ATA) and European Thyroid Associations’ (ETA) risk classifications in the management of pediatric patients with differentiated thyroid cancer (DTC). Materials and Methods The current study included 50 pediatric patients with DTC who were treated with total or near total thyroidectomy and radioiodine ablation whose risk assessment was initially defined according to the ATA and ETA guidelines. During the two years after initial treatment, patients were reclassified according to their DRS. Results The study showed that the ability of the DRS system to predict the final outcome was superior to that of the ATA and ETA guidelines. The observed variance in predicting final outcome was 2.3 % for ETA, 14.8 % for ATA, and 83.4 % for DRS. In intermediate/high-risk patients, according to the ATA/ETA guidelines, an excellent response to initial therapy resulted in a noteworthy reduction (about 40 %) for detection of structural disease at the time of final follow-up. The risk of structural disease at the time of final follow-up was significantly higher in the structural incomplete response group (HR = 23.34, P = 0.00) and biochemical incomplete response group (HR = 13.83, P = 0.03) than in the excellent response group. Conclusion The data documented the significance of re-stratifying pediatric patients with DTC on the basis of the findings obtained at the time of or after their initial therapy (total thyroidectomy and radioiodine ablation), predominantly in the intermediate/high-risk patients. In addition, DRS helped to better modulate the later follow-up, excluding a large number of intermediate/high risk patients from needless intensive workups, allowing personalization of follow-up management.

scholarly journals Differentiated Thyroid Cancer with Biochemical Incomplete Response: Clinico-Pathological Characteristics and Long Term Disease Outcomes

Cancers ◽  
2021 ◽  
Vol 13 (21) ◽  
pp. 5422
Author(s):  
Miriam Steinschneider ◽  
Jacob Pitaro ◽  
Shlomit Koren ◽  
Yuval Mizrakli ◽  
Carlos Benbassat ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
Differentiated Thyroid Cancer ◽  
Staging System ◽  
Response To Therapy ◽  
American Thyroid Association ◽  
Incomplete Response ◽  
Structural Disease ◽  
Stratification System

Although most patients with differentiated thyroid cancer (DTC) and biochemical incomplete response (BIR) follow a good clinical outcome, progression to structural disease may occur in 8–17% of patients. We aimed to identify factors that could predict the long-term outcomes of BIR patients. To this end, we conducted a retrospective review study of 1049 charts from our Differential Thyroid Cancer registry of patients who were initially treated with total thyroidectomy between 1962 and 2019. BIR was defined as suppressed thyroglobulin (Tg) > 1 ng/mL, stimulated Tg > 10 ng/mL or rising anti-Tg antibodies, who did not have structural evidence of disease, and who were assessed 12–24 months after initial treatment. We found 83 patients (7.9%) matching the definition of BIR. During a mean follow-up of 12 ± 6.6 years, 49 (59%) patients remained in a state of BIR or reverted to no evidence of disease, while 34 (41%) progressed to structural disease. At the last follow-up, three cases (3.6%) were recorded as disease-related death. The American Thyroid Association (ATA) Initial Risk Stratification system and/or AJCC/TNM (8th ed.) staging system at diagnosis predicted the shift from BIR to structural disease, irrespective of their postoperative Tg levels. We conclude that albeit 41% of BIR patients may shift to structural disease, and most have a rather indolent disease. Specific new individual data enable the Response to Therapy reclassification to become a dynamic system to allow for the better management of BIR patients in the long term.

scholarly journals OR21-07 The 2015 American Thyroid Association Risk Stratification System Is a Predictor of Persistent Disease in Real-World Clinical Practice

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Giorgio Grani ◽  
Marco Alfo’ ◽  
Valeria Ramundo ◽  
Efisio Puxeddu ◽  
Emanuela Arvat ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
High Risk ◽  
Risk Stratification ◽  
Real World ◽  
Initial Treatment ◽  
Response To Treatment ◽  
American Thyroid Association ◽  
Structural Disease ◽  
Stratification System ◽  
Risk Stratification System

Abstract Background. Management and follow-up of differentiated thyroid cancer (DTC) are guided by the likelihood of disease persistence or recurrence. The American Thyroid Association (ATA) practice guidelines provide a risk-estimation system based on data mainly derived by retrospective, single-center, and small cohorts. Aim. To validate the ATA risk-stratification system in predicting persistent structural disease. Methods. We analyzed data from the Italian Thyroid Cancer Observatory’s observational, web-based database, which prospectively enrolls newly diagnosed DTC patients in 40 Italian centers. For the present study we selected consecutive cases satisfying the inclusion criteria: 1) histological diagnosis of DTC, including papillary, follicular, and poorly differentiated tumors; 2) registration in the ITCO database between January 1, 2013 and April 23, 2019; 3) clinical evaluation between 6 and 18 month after primary treatment, including enough data to estimate the response to the initial treatment. Exclusion criteria were: histological diagnosis of NIFTP, medullary, or anaplastic thyroid cancer. The response to the initial treatment was categorized as excellent, biochemical incomplete, structural incomplete, or indeterminate based on imaging findings (neck ultrasound and other imaging studies, if performed), basal or stimulated serum thyroglobulin levels, and anti-Tg antibody levels. To model the response to treatment, we used a cumulative link model; given the hierarchical structure of the data, with patients nested within centers, we used a mixed-effect model, with a center-specific intercept summarizing unobserved center-specific characteristics. Results. Complete data about initial treatment and response to treatment after 6-18 months since initial treatment was available for 2071 patients. According to the ATA system, 1109 patients (53.6%) were classified as low-risk, 796 (38.4%) as intermediate, and 166 (8.0%) as high-risk. Excellent response was recorded in 1576 (76.1%) patients, indeterminate in 376 (18.2%), biochemical incomplete in 33 (1.6%), and structural incomplete in 86 (4.2%).The ATA risk stratification system is a significant predictor of response to treatment after 6-18 months: classification as intermediate- and high-risk increased the likelihood of a response worse than excellent (OR 1.68 [95% confidence intervals, CI 1.34-2.10] and 3.23 [95% CI 2.23-4.67], respectively), and a persistent structural disease (OR 4.67 [95% CI 2.59-8.43] and 16.48 [95% CI 7.87-34.5], respectively. In both analyses, the effect of the center (taking into account center-specific features) was negligible and not statistically significant. Conclusion. The 2015 ATA risk stratification system is a reliable predictor of short-term outcomes in patients with DTC, also if applied in a real-world setting consisting of several different clinical sites.

scholarly journals Modified dynamic risk stratification for predicting recurrence using the response to initial therapy in patients with differentiated thyroid carcinoma

2014 ◽  
Vol 170 (1) ◽  
pp. 23-30 ◽  
Author(s):  
Min Ji Jeon ◽  
Won Gu Kim ◽  
Woo Ri Park ◽  
Ji Min Han ◽  
Tae Yong Kim ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Differentiated Thyroid Carcinoma ◽  
Initial Therapy ◽  
Dynamic Risk ◽  
Incomplete Response ◽  
The Status ◽  
Stratification System ◽  
Response Group ◽  
Risk Stratification System

ObjectiveA new risk stratification system was proposed to estimate the risk of recurrence in patients with differentiated thyroid carcinoma (DTC) using the response to initial therapy. Here, we describe the modified dynamic risk stratification system, which takes into consideration the status of serum anti-Tg antibody (TgAb), and validate this system for assessing the risk of recurrence in patients with DTC.Patients and methodsPatients who underwent total thyroidectomy with radioiodine remnant ablation due to DTC between 2000 and 2005 were included. We classified patients into four groups based on the response to the initial therapy (‘excellent’, ‘acceptable’, ‘biochemical incomplete’, and ‘structural incomplete’ response).ResultsThe median follow-up period of 715 patients with DTC was 8 years. The response to initial therapy was an important risk predictor for recurrent/persistent DTC. The relative risks (95% CI) of recurrence were 16.5 (6.3–43.0) in the ‘acceptable response’ group, 41.3 (15.4–110.8) in the ‘biochemical incomplete response’ group, and 281.2 (112.9–700.5) in the ‘structural incomplete response’ group compared with the ‘excellent response’ group (P<0.001,P<0.001, andP<0.001 respectively). The disease-free survival rate of the ‘excellent response’ group to initial therapy was 98.3% whereas that of the ‘structural incomplete response’ group was only 6.8%.ConclusionsOur study validates the usefulness of the modified dynamic risk stratification system including the status of serum TgAb for predicting recurrent/persistent disease in patients with DTC. Personalized risk assessment using the response to initial therapy could be useful for the follow-up and management of patients with DTC.

scholarly journals Lobectomy in patients with differentiated thyroid cancer: indications and follow-up

2019 ◽  
Vol 26 (7) ◽  
pp. R381-R393 ◽  
Author(s):  
Jae Hyun Park ◽  
Jong Ho Yoon
Keyword(s):  
Risk Factors ◽  
Thyroid Carcinoma ◽  
Risk Stratification ◽  
Initial Therapy ◽  
Thyroid Lobectomy ◽  
Long Term Follow Up ◽  
Stratification System ◽  
Risk Stratification System

The extent of thyroid surgery for patients with low- and intermediate-risk differentiated thyroid carcinoma (DTC), with a primary tumour <4 cm and no extrathyroidal extension (ETE) or lymph node (LN) metastases, has shifted in a more conservative direction. However, clinicopathological risk factors, including microscopic ETE, aggressive histology, vascular invasion in papillary thyroid carcinoma (PTC) and intermediate volume of LN metastases, can only be identified after completing thyroid lobectomy. It is controversial whether patients with these risk factors should immediately undergo complete thyroidectomy and/or radioactive iodine remnant ablation or should be monitored without further treatments. Data are conflicting about the prognostic impact of these risk factors on clinical DTC outcomes. Notably, the recurrence rate in patients who underwent thyroid lobectomy is low and the few recurrences that develop during long-term follow-up can readily be detected by neck ultrasonography and treated by salvage surgery with no impact on survival. These findings suggest that a more conservative approach may be a preferred management strategy over immediate completion surgery, despite a slightly higher risk of structural recurrence. Regarding follow-up of post-lobectomy DTC patients, it is reasonable that an initial risk stratification system based on clinicohistological findings be used to guide the short-term follow-up prior to evaluating the response to initial therapy and that the dynamic risk stratification system based on the response to initial therapy be used to guide long-term follow-up.

Prognostic implications of pre-ablation stimulated Tg: a retrospective analysis of 2500 thyroid cancer patients

2021 ◽  
Author(s):  
Tian Tian ◽  
Yangmengyuan Xu ◽  
Xinyue Zhang ◽  
Bin Liu
Keyword(s):  
Thyroid Cancer ◽  
High Risk ◽  
Risk Stratification ◽  
Clinical Outcomes ◽  
Recurrent Disease ◽  
Clinicopathological Parameters ◽  
Characteristic Analysis ◽  
High Risk Patients ◽  
Risk Patients ◽  
Risk Categories

Abstract Context The risk of persistent and recurrent disease in patients with differentiated thyroid cancer (DTC) is a continuum that ranges from very low to very high, even within the three primary risk categories. It is important to identify independent clinicopathological parameters to accurately predict clinical outcomes. Objective To examine the association between pre-ablation stimulated thyroglobulin (ps-Tg) and persistent and recurrent disease in DTC patients and investigate whether incorporation of ps-Tg could provide a more individualized estimate of clinical outcomes. Design, Setting, and Participants Medical records of 2524 DTC patients who underwent total thyroidectomy and radioiodine ablation between 2006 and 2018 were retrospectively reviewed. Main Outcome Measure Ps-Tg was measured under thyroid hormone withdrawal before remnant ablation. Association of ps-Tg and clinical outcomes. Results In multivariate analysis, age, ATA risk stratification, M1, ps-Tg and cumulative administered activities were the independent predictive factors for persistent/ recurrent disease. Receiver operating characteristic analysis identified ps-Tg cutoff (≤ 10.1 ng/mL) to predict disease free status with a negative predictive value of 95%, and validated for all ATA categories. Integration of ps-Tg into ATA risk categories indicated that the presence of ps-Tg ≤ 10.1 ng/mL was associated with a significantly decreased chance of having persistent/recurrent disease in intermediate- and high-risk patients (9.9 to 4.1% in intermediate-risk patients, and 33.1 to 8.5% in high-risk patients). Conclusion Ps-Tg (≤ 10.1 ng/mL) was a key predictor of clinical outcomes in DTC patients. Its incorporation as a variable in the ATA risk stratification system could more accurately predict clinical outcomes.

scholarly journals Dynamic risk stratification in the follow-up of thyroid cancer: what is still to be discovered in 2017?

2017 ◽  
Vol 24 (11) ◽  
pp. R387-R402 ◽  
Author(s):  
Jolanta Krajewska ◽  
Ewa Chmielik ◽  
Barbara Jarząb
Keyword(s):  
Thyroid Cancer ◽  
Thyroid Carcinoma ◽  
Risk Stratification ◽  
Prospective Studies ◽  
Response To Treatment ◽  
Dynamic Risk ◽  
Primary Surgery ◽  
Risk Patients ◽  
Near Future

The adequate risk stratification in thyroid carcinoma is crucial to avoid on one hand the overtreatment of low-risk and on the other hand the undertreatment of high-risk patients. The question how to properly assess the risk of relapse has been discussed during recent years and resulted in a substantial change in our approach to risk stratification in differentiated thyroid cancer, proposed by the newest ATA guidelines. First initial risk stratification, based on histopathological data is carried out just after primary surgery. It should be emphasized, that a high quality of histopathological report is crucial for proper risk stratification. Next, during the follow-up, patients are restratified considering their response to treatment applied and classified to one of the following categories: excellent response, biochemical incomplete response, structural incomplete or indeterminate response. This new approach is called dynamic risk stratification as, in contrary to the previous rigid evaluation performed at diagnosis, reflects a real-time prognosis and thereby substantially influences and personalizes disease management. In this review, we raise some unresolved questions, among them the lack of prospective studies, fulfilling evidence-based criteria, necessary to validate this model of risk stratification. We also provided some data concerning the use of dynamic risk stratification in medullary thyroid cancer, not yet reflected in ATA guidelines. In conclusion, dynamic risk stratification allows for better prediction of the risk of recurrence in thyroid carcinoma, what has been demonstrated in numerous retrospective analyses. However, the validation of this approach in prospective studies seems to be our task for near future.

scholarly journals Clinical Predictors of Mortality in Prehospital Distress Calls by Emergency Medical Service Subscribers

2021 ◽  
Vol 10 (22) ◽  
pp. 5355
Author(s):  
Gabby Elbaz-Greener ◽  
Shemy Carasso ◽  
Elad Maor ◽  
Lior Gallimidi ◽  
Merav Yarkoni ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Population Based ◽  
Hospital Data ◽  
Clinical Predictors ◽  
Emergency Calls ◽  
Emergency Medical ◽  
Risk Patients ◽  
Early Decision ◽  
Risk Predictors

(1) Introduction: Most studies rely on in-hospital data to predict cardiovascular risk and do not include prehospital information that is substantially important for early decision making. The aim of the study was to define clinical parameters in the prehospital setting, which may affect clinical outcomes. (2) Methods: In this population-based study, we performed a retrospective analysis of emergency calls that were made by patients to the largest private emergency medical services (EMS) in Israel, SHL Telemedicine Ltd., who were treated on-site by the EMS team. Demographics, clinical characteristics, and clinical outcomes were analyzed. Mortality was evaluated at three time points: 1, 3, and 12 months’ follow-up. The first EMS prehospital measurements of the systolic blood pressure (SBP) were recorded and analyzed. Logistic regression analyses were performed. (3) Results: A total of 64,320 emergency calls were included with a follow-up of 12 months post index EMS call. Fifty-five percent of patients were men and the mean age was 70.2 ± 13.1 years. During follow-up of 12 months, 7.6% of patients died. Age above 80 years (OR 3.34; 95% CI 3.03–3.69, p < 0.005), first EMS SBP ≤ 130 mm Hg (OR 2.61; 95% CI 2.36–2.88, p < 0.005), dyspnea at presentation (OR 2.55; 95% CI 2.29–2.83, p < 0001), and chest pain with ischemic ECG changes (OR 1.95; 95% CI 1.71–2.23, p < 0.001) were the highest predictors of 1 month mortality and remained so for mortality at 3 and 12 months. In contrast, history of hypertension and first EMS prehospital SBP ≥ 160 mm Hg were significantly associated with decreased mortality at 1, 3 and 12 months. (4) Conclusions: We identified risk predictors for all-cause mortality in a large cohort of patients during prehospital EMS calls. Age over 80 years, first EMS-documented prehospital SBP < 130 mm Hg, and dyspnea at presentation were the most profound risk predictors for short- and long-term mortality. The current study demonstrates that in prehospital EMS call settings, several parameters can be used to improve prioritization and management of high-risk patients.

The Influence of Age on Disease Outcome in 2015 ATA High Risk Differentiated Thyroid Cancer Patients

2021 ◽  
Author(s):  
Evert F.s. van Velsen ◽  
Robin P. Peeters ◽  
Merel T. Stegenga ◽  
F.j. van Kemenade ◽  
Tessa M. van Ginhoven ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
High Risk ◽  
Risk Stratification ◽  
Differentiated Thyroid Cancer ◽  
Response To Therapy ◽  
Disease Outcome ◽  
High Risk Patients ◽  
Risk Patients ◽  
Stratification System ◽  
Risk Stratification System

Objective Recent research suggests that the addition of age improves the 2015 American Thyroid Association (ATA) Risk Stratification System for differentiated thyroid cancer (DTC). The aim of our study was to investigate the influence of age on disease outcome in ATA High Risk patients with a focus on differences between patients with papillary (PTC) and follicular thyroid cancer (FTC). Methods We retrospectively studied adult patients with High Risk DTC from a Dutch university hospital. Logistic regression and Cox proportional hazards models were used to estimate the effects of age (at diagnosis) and several age cutoffs (per five years increment between 20 and 80 years) on (i) response to therapy, (ii) developing no evidence of disease (NED), (iii) recurrence, and (iv) disease specific mortality (DSM). Results We included 236 ATA High Risk patients (32% FTC) with a median follow-up of 6 years. Age, either continuously or dichotomously, had a significant influence on having an excellent response after initial therapy, developing NED, recurrence, and DSM for PTC and FTC. For FTC, an age cutoff of 65 or 70 years showed the best statistical model performance, while this was 50 or 60 years for PTC. Conclusions In a population of patients with High Risk DTC, older age has a significant negative influence on disease outcomes. Slightly different optimal age cutoffs were identified for the different outcomes, and these cutoffs differed between PTC and FTC. Therefore, the ATA Risk Stratification System may further improve should age be incorporated as an additional risk factor.

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