This document summarizes recent advances in the diagnosis and treatment of thyroid cancer by Professor Steven Boyages. It discusses the rising incidence of thyroid cancer in recent decades, which may be due to increased medical surveillance and technology. It describes a study that examined pathways to diagnosis for thyroid cancer patients in New South Wales, finding most were serendipitous discoveries. Factors like tumor size influenced diagnosis pathways. Minimally invasive thyroidectomy techniques and strategies for radioiodine ablation in low-risk thyroid cancer, including using recombinant human thyrotropin and lower radiation doses, are also summarized. Treatment of radioiodine-resistant thyroid cancer is an ongoing challenge.
Last update of thyroid cancer management from diagnosis till follow up
You can request other lectures by emailing me at salahmab76@yahoo.com or calling me 0020 100 408 1234
Dr Salah Mabrouk Khallaf
First Approach to Automatic Performance Status Evaluation and Physical Activi...Oresti Banos
The evaluation of cancer patients’ recovery is still under the big subjectivity of physicians. Many different systems have been successfully implemented for physical activity evaluation, nonetheless there is still a big leap into Performance Status evaluation with ECOG and Karnofsky’s Performance Status scores. An automatic system for data recovering based on Android smartphone and wearables has been developed. A gamification implementation has been designed for increasing patients’ motivation in their recovery. Furthermore, novel and without-precedent algorithms for Performance Status (PS) and Physical Activity (PA) assessment have been developed to help oncologists in their diagnoses.
Last update of thyroid cancer management from diagnosis till follow up
You can request other lectures by emailing me at salahmab76@yahoo.com or calling me 0020 100 408 1234
Dr Salah Mabrouk Khallaf
First Approach to Automatic Performance Status Evaluation and Physical Activi...Oresti Banos
The evaluation of cancer patients’ recovery is still under the big subjectivity of physicians. Many different systems have been successfully implemented for physical activity evaluation, nonetheless there is still a big leap into Performance Status evaluation with ECOG and Karnofsky’s Performance Status scores. An automatic system for data recovering based on Android smartphone and wearables has been developed. A gamification implementation has been designed for increasing patients’ motivation in their recovery. Furthermore, novel and without-precedent algorithms for Performance Status (PS) and Physical Activity (PA) assessment have been developed to help oncologists in their diagnoses.
Comprehensive review of Isolated Axillary lymph nodal metastasis of unknown origin- Clinically unknown primary axilla which includes detailed approach and management of inguinal lymph nodal metastasis also
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Incidence of thyroid cancer is on the rise. In fact, according to the American Cancer Society, it's the most rapidly increasing cancer in the U.S., and in 2015, there were an estimated 62,450 new cases in the U.S. Learn about the different types of thyroid cancer, risk factors and current treatment options.
Thyroid cancer is treated at the Head and Neck Cancer Treatment Center at Dana-Farber/Brigham and Women's Cancer Center. Learn more at: http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Head-and-Neck-Cancer-Treatment-Center.aspx
A supercool powerpoint about thyroid cancer that is very hard to understand unless I am speaking to you and filling in the blanks so check out my blog and look for a related post:
http://m4tt5-b10-bl0g-2o1o.blogspot.com/
Comprehensive review of Isolated Axillary lymph nodal metastasis of unknown origin- Clinically unknown primary axilla which includes detailed approach and management of inguinal lymph nodal metastasis also
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Incidence of thyroid cancer is on the rise. In fact, according to the American Cancer Society, it's the most rapidly increasing cancer in the U.S., and in 2015, there were an estimated 62,450 new cases in the U.S. Learn about the different types of thyroid cancer, risk factors and current treatment options.
Thyroid cancer is treated at the Head and Neck Cancer Treatment Center at Dana-Farber/Brigham and Women's Cancer Center. Learn more at: http://www.dana-farber.org/Adult-Care/Treatment-and-Support/Treatment-Centers-and-Clinical-Services/Head-and-Neck-Cancer-Treatment-Center.aspx
A supercool powerpoint about thyroid cancer that is very hard to understand unless I am speaking to you and filling in the blanks so check out my blog and look for a related post:
http://m4tt5-b10-bl0g-2o1o.blogspot.com/
Multidisciplinary Approach to Prostate Cancer and Changes in Treatment Decisi...CrimsonpublishersCancer
In order to demonstrate the impact of multi-disciplinary care in the community oncology setting, we evaluated treatment decisions following the initiation of a dedicated genitourinary multi-disciplinary clinic (GUMDC).
This lecture proves an overview of assessing the thyrod nodule upon presentation. The use of imaging, including nuclear medicine, PET, CT/MR and Ultrasound is discussed.
There is more detail on ultrasound evaluation with particular emphasis on ACR TIRADS
Advances in the diagnosis and treatment for benign and malignant thyroid diseaseHealthXn
Thyroid disorders are common. This presentation reviews the causes of benign thyroid disease as well as therapy, including new therapies for advanced thyroid cancer.
How general internists can participate in the continuum of care for patients with cancer. (Talk given at Internal Medicine Grand Rounds, St. Elizabeth Hospital, General Santos City, 10 Feb 2021.)
Sex-Based Difference in Gene Alterations and Biomarkers in Anal Squamous Cell...semualkaira
anal squamous cell carcinoma (ASCC) is a relatively rare malignancy ac-counting for about 2-3% of all the gastrointestinal tumors. The standard of treatment for localized disease is chemoradiotherapy
Similar to Recent advances in the diagnosis and treatment of thyroid cancer (20)
Preventing diabetes and obesity in mental health disordersHealthXn
Diabetes is common in people with mental health disorders. This presentation discusses why and what therapies may worsen the disorder and how to prevent obesity and diabetes
Iodine and the Thyroid: How the thyroid uniquely adapts to its environment to...HealthXn
This presentation describes how the thyroid actively traps iodine, a rare micronutrient, to produce thyroid hormones. Iodine is important for normal fetal and adult development.
This presentation given to the International Society for Enzymology in Corfu details the extent of vitamin D deficiency in the largest state of Australia, NSW. It highlights the over=testing phenomenon that has occurred and how to correct the problem.
The value of health information systems and EMR to patient careHealthXn
This presentation given to the Athena Society in Crete documents the challenges and benefits of health information systems and the difficulties encountered in implementing EMR.
Bridging health care’s innovation education gapHealthXn
Recently I was privileged to be part of a consultation bringing together CEOS in health, academia and business to examine health care's innovation education. Regina Herzlinger and co authors have distilled these consultations into this thought provoking article.
https://hbr.org/2014/11/bridging-health-cares-innovation-education-gap
Prevention against micronutrient malnutritionHealthXn
Micronutrident disorders are common and a major cause of morbidity in all populations. In this presentation we discuss the importance of iodine, folic acid and vitamin D deficiency. Prevention is the solution
The impact of maternal and fetal thyroid hormone deficiency: iodine deficienc...HealthXn
Thyroid hormone deficiency at critical periods of brain development may cause permanent mental and neurological disability and impairment. Iodine deficiency is the commonest preventable cause of mental disability
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
7. Rising incidence of thyroid cancer
Over the past few decades an increase in the
incidence of thyroid cancer has been recorded
in many countries around the world, and has
been particularly marked in the Australian state
of New South Wales (NSW).
The reasons for this increase remain unclear, but
heightened medical surveillance and increased
technological sensitivity could be contributing
to greater detection of asymptomatic disease.
8. Objective
To describe the pathways to diagnosis of thyroid
cancer for a cohort of newly diagnosed
patients in NSW and compare these pathways
in groups of people defined by age, gender,
place of residence, ethnic background and
medical insurance status.
Pathways to the diagnosis of thyroid cancer in New South Wales: a population-based
cross-sectional study.Kahn C, Simonella L, Sywak M, Boyages S, Ung O, O'Connell
D.Cancer Causes Control. 2012 Jan; 23(1):35-44. Epub 2011 Oct 15
9. Methods
Newly diagnosed cases of thyroid cancer
(n=452) were identified and recruited through
the population-based NSW Central Cancer
Registry.
Participants completed a questionnaire and diary
of doctor visits and investigations that led to
their diagnosis.
Tumour characteristics were obtained from
pathology reports.
11. Results
60% of patients had their cancer discovered
serendipitously, while 40% initially presented to
their doctor with a lump or symptom specific to
thyroid cancer.
The pathways to diagnosis varied significantly
with tumour size (p=0.001) and also by age in
men and place of residence in women
(p=0.008 and p=0.05 respectively).
12. Pathways of detection for thyroid
cancer NSW
Pathway
Patient
detected
Doctor
detected
Men n=108
Women n=344
Total n=452
Weighted
n
%
n
%
n
%
%*
39
36.1
140
40.7
179
39.6
38.8
23
21.3
49
14.2
72
15.9
16.4
Imaging
After benign
disease
22
20.4
28
8.1
50
11.1
10.9
14
13
104
30.2
118
26.1
26.2
Other
10
9.3
23
6.7
33
7.3
7.6
Table 3: Pathways to the diagnosis of thyroid cancer in men and women in NSW, Australia
* Weighted to population distribution by place of residence
13. Factors associated with
pathways to diagnosis
The pathways to diagnosis varied significantly by
age group (p=0.009), sex (p<0.001), tumour size
(p<0.001), spread of cancer at diagnosis
(p=0.006), treatment for another disease at time of
diagnosis (p=0.02), and current work status
(p=0.001).
Variables that were not statistically significantly
associated with the pathways to diagnosis
included health insurance status, education level,
smoking, alcohol consumption, number of other
illnesses, previous cancer, family history of thyroid
cancer, time from last pregnancy for women, and
cancer type.
14. Multi-regression model
After adjusting for all factors in the model the only factor
that differed significantly across the pathway groups
was tumour size (p=0.001).
The odds of a patient with a large tumour (>3cm) being
initially detected by a doctor (vs patient detected) were
66% (OR=0.34, 95% CI 0.1, 0.9) lower than a patient
with a small tumour (<1cm).
Patients with large tumours also had 60% (OR=0.4, 95%
CI 0.2, 0.9) lower odds of being detected after treatment
for benign thyroid disease (vs patient detected) than
patients with a tumour less than 1cm.
Patients with tumours between 2 and 3 cm had 6.85
greater odds (95% CI 2.3, 20.7) of being diagnosed as
an incidental finding of imaging (vs patient detected)
than patients with a tumour less than 1cm.
15. Conclusion
As the majority of participants had serendipitous
diagnoses, the reported incidence of thyroid
cancer is likely to be influenced by diagnostic
technology and medical surveillance practices.
16. Dilemma
Nodular thyroid disease is common and the
incidence of thyroid cancer is rising
Increasing cost of over-investigation leading to
the potential for unnecessary surgery and
unnecessary aggressive treatment for thyroid
cancer
Implications for Diagnosis; Surgery; and
radioactive iodine therapy
17.
18. Original Article
Preoperative Diagnosis of Benign Thyroid Nodules
with Indeterminate Cytology
Erik K. Alexander, M.D., Giulia C. Kennedy, Ph.D., Zubair W. Baloch, M.D., Ph.D.,
Edmund S. Cibas, M.D., Darya Chudova, Ph.D., James Diggans, Ph.D., Lyssa
Friedman, R.N., M.P.A., Richard T. Kloos, M.D., Virginia A. LiVolsi, M.D., Susan J.
Mandel, M.D., M.P.H., Stephen S. Raab, M.D., Juan Rosai, M.D., David L.
Steward, M.D., P. Sean Walsh, M.P.H., Jonathan I. Wilde, Ph.D., Martha A.
Zeiger, M.D., Richard B. Lanman, M.D., and Bryan R. Haugen, M.D.
N Engl J Med
Volume 367(8):705-715
August 23, 2012
19. Study Overview
• A significant fraction of fine-needle aspirates obtained from thyroid
nodules are read as indeterminate.
• A new molecular test accurately predicts whether a cytologically
indeterminate nodule is benign 93% of the time, permitting a
conservative approach to management.
21. Results
Of the 265 indeterminate nodules, 85 were malignant. The
gene-expression classifier correctly identified 78 of the
85 nodules as suspicious (92% sensitivity; 95%
confidence interval [CI], 84 to 97), with a specificity of
52% (95% CI, 44 to 59).
The negative predictive values for “atypia (or follicular
lesion) of undetermined clinical significance,” “follicular
neoplasm or lesion suspicious for follicular neoplasm,”
or “suspicious cytologic findings” were 95%, 94%, and
85%, respectively.
Analysis of 7 aspirates with false negative results
revealed that 6 had a paucity of thyroid follicular cells,
suggesting insufficient sampling of the nodule.
23. Conclusions
• These data suggest consideration of a more conservative approach for
most patients with thyroid nodules that are cytologically indeterminate
on fine-needle aspiration and benign according to gene-expression
classifier results.
27. Should Prophylactic Central (Level 6)
Lymph Node Dissections be Performed?
There is agreement that therapeutic central and lateral lymph node dissections should be
performed at the time of total thyroidectomy when lymph nodes are suspicious or proved to
harbor cancer by sonographic appearance or by FNA analyses preoperatively or when
suspicious lymph nodes are found at operation. Prophylactic lateral lymph node dissections
were common in the past, but have been abandoned for several decades or longer.
Recently, Delbridge and his group and others have proposed that unilateral or bilateral
prophylactic central lymph node dissections (level 6 dissections) with parathyroid
autotransplantation be performed in all cases of papillary thyroid cancer at the time of total
thyroidectomy. This, they state, might decrease mortality from thyroid cancer, would greatly
decrease recurrence of cancer, and would further clarify who needs radioiodine therapy
postoperatively. Some studies by very experienced surgeons demonstrate no increase in
hypoparathyroidism or recurrent laryngeal nerve injuries after this procedure, while other
equally competent surgeons have found an increase in permanent hypoparathyroidism.
We and others do not routinely perform this procedure because of the increased risk of
hypoparathyroidism, but reserve it for cases in which ipsilateral central lymph nodes are clearly
involved with tumor. 27d
29. Original Article
Strategies of Radioiodine Ablation in Patients with
Low-Risk Thyroid Cancer
Martin Schlumberger, M.D., Bogdan Catargi, M.D., Ph.D., Isabelle Borget, Pharm.D.,
Ph.D., Désirée Deandreis, M.D., Slimane Zerdoud, M.D., Boumédiène Bridji, M.D.,
Ph.D., Stéphane Bardet, M.D., Laurence Leenhardt, M.D., Ph.D., Delphine
Bastie, M.D., Claire Schvartz, M.D., Pierre Vera, M.D., Ph.D., Olivier Morel, M.D.,
Danielle Benisvy, M.D., Claire Bournaud, M.D., Françoise Bonichon, M.D., Catherine
Dejax, M.D., Marie-Elisabeth Toubert, M.D., Sophie Leboulleux, M.D., Marcel
Ricard, Ph.D., Ellen Benhamou, M.D., for the Tumeurs de la Thyroïde Refractaires
Network for the Essai Stimulation Ablation Equivalence Trial
N Engl J Med
Volume 366(18):1663-1673
May 3, 2012
30. Study Overview
• This trial compared two thyrotropin-stimulation methods and two 131I
doses for postoperative ablation in patients with low-risk thyroid
cancer.
• Rates of ablation were similar in all treatment groups.
• Doses lower than those currently recommended may be adequate for
this condition.
32. Initial Characteristics of the 752 Randomized Patients, According to Thyrotropin-Stimulation
Method and 131I Dose.
Schlumberger M et al. N Engl J Med 2012;366:1663-1673
33. Follow-up Testing of Thyroid Ablation 6–10 Months after 131I Administration in the 684 Patients
Who Could Be Evaluated, According to Thyrotropin-Stimulation Method and 131I Dose.
Schlumberger M et al. N Engl J Med 2012;366:1663-1673
34. Adverse Events, According to Thyrotropin-Stimulation Method and 131I Dose.
Schlumberger M et al. N Engl J Med 2012;366:1663-1673
35. Conclusions
• The use of recombinant human thyrotropin and low-dose (1.1 GBq)
postoperative radioiodine ablation may be sufficient for the
management of low-risk thyroid cancer.
36. Original Article
Ablation with Low-Dose Radioiodine and
Thyrotropin Alfa in Thyroid Cancer
Ujjal Mallick, F.R.C.R., Clive Harmer, F.R.C.P., Beng Yap, F.R.C.P., Jonathan
Wadsley, F.R.C.R., Susan Clarke, F.R.C.P., Laura Moss, F.R.C.P., Alice
Nicol, Ph.D., Penelope M. Clark, F.R.C.Path., Kate Farnell, R.C.N., Ralph
McCready, D.Sc., James Smellie, M.D., Jayne A. Franklyn, F.Med.Sci., Rhys
John, F.R.C.Path., Christopher M. Nutting, M.D., Kate Newbold, F.R.C.R., Catherine
Lemon, F.R.C.R., Georgina Gerrard, F.R.C.R., Abdel Abdel-Hamid, F.R.C.R., John
Hardman, F.R.C.R., Elena Macias, M.D., Tom Roques, F.R.C.R., Stephen
Whitaker, M.D., Rengarajan Vijayan, F.R.C.R., Pablo Alvarez, M.Sc., Sandy
Beare, Ph.D., Sharon Forsyth, B.Sc., Latha Kadalayil, Ph.D., and Allan
Hackshaw, M.Sc.
N Engl J Med
Volume 366(18):1674-1685
May 3, 2012
37. Study Overview
• In this trial, low-dose radioiodine was as effective as high-dose
radioiodine in patients with differentiated thyroid tumors, and
recombinant human thyrotropin (thyrotropin alfa) was as effective as
thyroid hormone withdrawal.
38. Days of Hospital Isolation, According to Radioiodine Dose.
Mallick U et al. N Engl J Med 2012;366:1674-1685
42. RAI resistance
The cure rates for DTC are generally high when
patients are treated with surgery or RAI. However,
between 5% and 15% of patients develop RAI
resistance, and these patients typically have an
expected survival of 2.5 to 3.5 years.
No standard therapy exists for patients who
experience disease progression.
New agents that either induce sodium iodide
symporter activity or that inhibit tyrosine kinase
inhibitor
o Sorafenib
o Selumetinib
43.
44. Sorefenib
Sorafenib, a tyrosine kinase inhibitor, inhibits multiple kinases,
including the Raf kinase, VEGFR-1, VEGFR-2, VEGFR-3,
PDGFR-B, KIT, FLT-3 and RET, which are associated with
tumor cell proliferation and angiogenesis.
The drug is currently approved by the FDA to treat unresectable
hepatocellular carcinoma and advanced renal cell carcinoma.
45. Original Article
Selumetinib-Enhanced Radioiodine Uptake in
Advanced Thyroid Cancer
Alan L. Ho, M.D., Ph.D., Ravinder K. Grewal, M.D., Rebecca Leboeuf, M.D., Eric J.
Sherman, M.D., David G. Pfister, M.D., Desiree Deandreis, M.D., Keith S. Pentlow,
M.Sc., Pat B. Zanzonico, Ph.D., Sofia Haque, M.D., Somali Gavane, M.D., Ronald A.
Ghossein, M.D., Julio C. Ricarte-Filho, Ph.D., José M. Domínguez, M.D., Ronglai
Shen, Ph.D., R. Michael Tuttle, M.D., Steve M. Larson, M.D., and James A. Fagin,
M.D.
N Engl J Med
Volume 368(7):623-632
February 14, 2013
46. Study Overview
• Inhibition of mitogen-activated protein kinase resulted in an increase in
expression of the sodium–iodide symporter in 12 of 20 patients, 8 of
whom had sufficient uptake to warrant treatment with radioiodine.
• Five patients had a response, and 3 had stable disease.
47. Protocol Design and Changes in Iodine Uptake.
Ho AL et al. N Engl J Med 2013;368:623-632
48. Iodine-124 PET-CT Scans Obtained before and after Selumetinib Treatment in Selected Patients
with Positive Responses.
Ho AL et al. N Engl J Med 2013;368:623-632
49. Quantification of Iodine-124 PET Uptake in a Lesion in a Patient with an NRAS Mutation Who
Later Received Radioiodine.
Ho AL et al. N Engl J Med 2013;368:623-632
50. Conclusions
• Selumetinib produces clinically meaningful increases in iodine uptake
and retention in a subgroup of patients with thyroid cancer that is
refractory to radioiodine; the effectiveness may be greater in patients
with RAS-mutant disease.
Editor's Notes
Figure 1. Algorithm for Evaluating Thyroid Nodules. The gene-expression classifier profile allows cytologically indeterminate fine-needle aspirates to be divided into either benign or suspicious groups, thereby informing the need for and extent of surgery. AUS–FLUS denotes atypical or follicular lesion of undetermined significance, FNA fine-needle aspiration, and FN–SFN follicular neoplasm or lesion suggestive of follicular neoplasm.
Figure 1 Randomization and Follow-up of the Study Patients. The tumor–node–metastasis (TNM) stage noted was ascertained on pathological examination of a surgical specimen of the tumor (pT) and lymph node (N). Stage Nx indicates that the lymph nodes could not be evaluated; stage N0, that tumor cells were absent from regional lymph nodes; and stage N1, that tumor cells were present in regional lymph nodes. Fifteen patients could not be evaluated because not all diagnostic tests were performed.
Table 1 Initial Characteristics of the 752 Randomized Patients, According to Thyrotropin-Stimulation Method and 131I Dose.
Table 3 Follow-up Testing of Thyroid Ablation 6–10 Months after 131I Administration in the 684 Patients Who Could Be Evaluated, According to Thyrotropin-Stimulation Method and 131I Dose.
Table 4 Adverse Events, According to Thyrotropin-Stimulation Method and 131I Dose.
Figure 1 Days of Hospital Isolation, According to Radioiodine Dose. Shown are the proportions of patients receiving low-dose radioiodine (1.1 GBq) or high-dose radioiodine (3.7 GBq) who spent 1 to 4 or more days in hospital isolation after ablation (P<0.001 by the chi-square test).
Table 1 Baseline Characteristics of the Patients.
Table 3 Symptoms Reported by Patients during the 4 Weeks before Ablation.
Figure 1 Protocol Design and Changes in Iodine Uptake. Panel A shows the protocol design. Baseline iodine avidity in the lesion was first assessed with thyrotropin alfa–stimulated iodine-124 positron-emission tomographic–computed tomographic (PET-CT) scanning. Patients were then treated with selumetinib at a dose of 75 mg given orally twice a day for 4 weeks. In the final week of treatment, a second thyrotropin alfa–stimulated 124I PET-CT study was performed. The double arrows indicate the two thyrotropin alfa injections. Patients with 124I dosimetry that predicted tumor uptake of less than 2000 cGy discontinued the study. If the absorbed dose of radioiodine in the lesion was predicted to be 2000 cGy or greater, full dosimetry with iodine-131 was performed to calculate the maximum tolerable activity that could be administered safely. Patients then received a therapeutic dose of radioiodine the next week after preparation with thyrotropin alfa. Selumetinib was continued until 2 days after the administration of therapeutic radioiodine. Thyroglobulin levels and the radiographic response were assessed at 2 and 6 months after radioiodine administration. Panel B shows a summary of the changes in iodine uptake quantified by 124I PET-CT and the number of patients who met the criteria for treatment with iodine-131.
Figure 2 Iodine-124 PET-CT Scans Obtained before and after Selumetinib Treatment in Selected Patients with Positive Responses. Panel A shows whole-body maximum-intensity projection images of a patient with a BRAF-mutant papillary thyroid cancer. New iodine uptake is shown in nearly all previously negative lung and neck metastases. Panel B shows fused axial PET-CT images of a patient with an NRAS-mutant, poorly differentiated thyroid cancer. Both new and significantly increased iodine uptake in lung metastases is shown. Panels C and D show PET-CT images from another patient with an NRAS-mutant, poorly differentiated thyroid cancer. In Panel C, fused axial PET-CT images show significantly increased iodine uptake in a sacroiliac bone metastasis after administration of selumetinib (right). In Panel D, fused axial images (top and bottom left) show new iodine uptake in a previously negative site as well as increased avidity in a large left parietal skull metastasis. Three-dimensional rendering highlights changes in the left parietal skull metastasis before and after selumetinib (top and bottom right).
Figure 3 Quantification of Iodine-124 PET Uptake in a Lesion in a Patient with an NRAS Mutation Who Later Received Radioiodine. Panel A shows the maximal standardized uptake value (SUVmax) for iodine in all tumors in a patient with an NRAS-mutant, poorly differentiated thyroid cancer. Each bar represents one malignant lesion identified on the iodine-124 PET-CT scan. The bars to the left indicate the increases in iodine-124 avidity achieved after selumetinib administration in lesions that absorbed some iodine at baseline. The bars on the right indicate selumetinib-induced changes in lesions that were negative for iodine at baseline. Panel B shows the SUVmax in every metastatic lesion identified in the same patient before and after the administration of selumetinib. The dashed lines mark points on the graph corresponding to different degrees of change in the SUVmax in the lesion after the administration of selumetinib. The red dashed line demarcates no change in iodine uptake after the administration of selumetinib (0%). Dashed lines to the left of the red dashed line represent graded percentage increases in iodine-124 uptake (+25%, +50%, and +100%), whereas the lines to the right represent graded percentage decreases (−25%, −50%, and −75%). Nearly all the metastatic lesions in this patient (circles) had more than a 100% increase in iodine uptake after administration of selumetinib. The SUVmax for a sternal metastasis was off the scale (it increased from 220 to 599 with selumetinib) and thus could not be included in these graphs without obscuring the data for the other 54 lesions analyzed.