"Clinicopathological features and treatment outcomes of differentiated thyroid cancer in Saudi children and adults"

Background

The incidence of differentiated thyroid cancers (DTC), including papillary (PTC) and follicular (FTC) variants, is increasing exponentially over the past years throughout the world with a wide geographic variation [1]. In Kingdom of Saudi Arabia, DTC is the second most common malignancy among middle aged women [2]. DTC is relatively uncommon in children (age 18 years or below), adolescents (under 25 years old), and young adults (above 25 and below 30 years) accounting for 3-10 %. Recent data has suggested that the frequency of DTC in children varies according to pre-puberty, puberty and adolescence growth phases [3, 4]. In contrast to adults, DTC in pre-pubertal children has some distinctive differences; such as (a) larger primary tumor at the time of diagnosis; (b) high prevalence of neck lymph nodes and distant metastases at the time of diagnosis; and (c) the high risk of recurrences [5].

DTC in children and adolescents is treated in similar fashion as that in adults, primarily because of rarity of disease in pediatric population and lack of availability of pediatric DTC treatment guidelines [6]. Fortunately, even with aggressive behavior, DTC in children has excellent prospects with use of thyroidectomy, neck dissection, radioactive iodine-131 (RAI) ablation and suppression of thyroid-stimulating hormone (TSH) secretion with levothyroxine [5, 6].

In the current study, we designed our approach towards the comparative analysis of different clinicopathological features and treatment outcomes among children, adolescents and young adults with DTC in Kingdom of Saudi Arabia.

Methods

After formal approval from the institutional ethical committee, medical records of 157 DTC patients of age less than 30 years, who were treated at our hospital during the period of July 2000 and December 2012 were reviewed using computer based database system.

For the purpose of present study, the study population was divided in three groups; (a) children (patients below or equal to the age of 18 years), (b) young adults (aged 19 to 25 years) and (c) adults (aged 26 to <?30 years) [7].

Demographic, clinicopathological and radiological data

Demographic and clinical data including age at the time of diagnosis, gender and symptomatology were reviewed. A detailed second review of all histopathological specimens was done by experienced histopathologist. Different histopathological characteristics, including tumor size, histopathologic variants, multifocality, tumor, lymph node and metastasis (TNM) staging were recorded. Data was collected from different imaging modalities including neck ultrasonography (USG), whole body I-131 scintigraphy (WBS), computed tomography (CT) scan of neck and chest and flourodeoxyglucose positron emission tomography (FDG-PET). Data regarding different treatment modalities including thyroidectomy, +/? neck dissection, adjuvant radioactive iodine-131 (RAI) ablation and its doses in millicurie (mCi) were also recorded.

Statistical analysis

The primary endpoint was the disease free survival (DFS). Secondary points were; the comparative analysis of different clinicopathological features of DTC in children and adults, locoregional control (LRC), distant metastasis control (DMC) and overall survival (OS) rates.

Local recurrence (LR) was defined as the duration between surgery date and date of clinically or radiologically detectable disease in the thyroid bed and/or in cervical lymph nodes on imaging (USG, WBS, CT and FDG-PET) after evaluation of elevated thyroglobulin (TG) levels. Distant metastasis (DM) was defined as the duration between surgery date and date of documented disease outside the neck on imaging after evaluating for elevated TG. DFS was defined as the duration between surgery date and date of documented disease reappearance/relapse, death from cancer and/or last follow-up. OS was defined as the duration between surgery date and date of patient death or last follow-up.

Chi-square or Student's t-tests were used to determine the differences in various clinical variables. Probabilities of LRC, DMC, DFS and OS rates were shown with the Kaplan-Meier method and the comparison for various survival curves was performed using log rank. All statistical analyses were performed using the computer program SPSS version 16.0.

Results

Demographic and clinicopathological features of cohort

The mean age at the time diagnosis of whole cohort was 22.7 years (range: 5-30). The whole cohort (n?=?157) was consisted of 134 (85.4 %) females and 23 (14.6 %) males. Male gender was predominant in children (25.9 %) than that in groups 19-25 years (10.3 %) and 26-30 years (15.4 %) respectively P?=?0.038. The predominant histopathology was PTC (95.5 %) whereas FTC was seen only in 4.5 % of patients. Mean tumor size was 2.9 cm (range: 0.4-6.5) without any statistically significant difference between the children and adults (P?=?0.653). In contrast to adults, positive lymph nodes were more evident in the children (74.1 %), P?=?0.012. According to ATA risk stratification classification, the children (85.2 %) were found to be at higher risk as compared to other age groups P?=?0.003. The clinicopathological and treatment characteristics are described in Table 1. [ Table Omitted - see PDF ]

Table 1

Comaprison of clinicopathological and treatment characteristics of children and adult patients with differentiated thyroid carcinoma at presentation

Variables

Children with DTC (<18 years)

Young adults with DTC (19-25 years)

Adults with DTC (26-30 years)

P value

(n =27)

(n =78)

(n =52)

Age (years)

Mean/range/SD

13.5 (5-18)?±?4.3

22.41?±?3.3

27.5?±?2.8

0.0001

<10 years

8 (29.6)

0

0

11-18 years

19 (70.4)

0

0

Gender, n (%)

?

?

?

?

M

7 (25.9)

8 (10.3)

8 (15.4)

0.038

F

20 (74.1)

70 (89.7)

44 (84.6)

0.160

Tumor size (cm)

?

?

?

?

Mean/range/SD

2.8 (0.8-6.5)?±?1.36

2.8 (0.8-6.4) ±1.36

2.9 (0.4-6.5) ±1.62

0.653

Histology n (%)

?

?

?

?

Papillary

27 (100)

72 (92.3)

51 (98.1)

0.605

Follicular

0

6 (7.7)

1 (1.9)

T stage, n (%)

?

?

?

?

T1

12 (44.4)

27 (34.6)

26 (50.0)

0.860

T2

11 (40.8)

34 (43.6)

15 (28.9)

T3

4 (14.8)

15 (19.2)

10 (19.2)

T4

0

2 (2.6)

1 (1.9)

N stage, n (%)

?

?

?

?

N0

7 (25.9)

42 (53.8)

32 (61.5)

0.012

N1

20 (74.1)

36 (46.2)

20 (38.5)

N1a

9 (45.0)

22 (61.1)

11 (55.0)

N1b

11 (55.0)

14 (38.9)

9 (45.0)

M stage, n (%)

?

?

?

?

M0

26 (96.3)

77 (98.7)

52 (100)

0.379

M1

1 (3.7)

1 (1.3)

0

LVSI, n (%)

?

?

?

?

Yes

12 (44.4)

27 (34.6)

16 (30.7)

0.031

No

15 (55.6)

51 (65.4)

36 (69.3)

Multifocality, n (%)

?

?

?

?

Yes

9 (33.3)

43 (55.2)

32 (61.5)

0.012

No

18 (66.6)

35 (44.8)

20 (38.5)

Risk stratification, n (%)

?

?

?

?

Low

2 (7.4)

17 (21.8)

11 (21.1)

0.003

Intermediate

2 (7.4)

23 (29.5)

21 (40.4)

High

23 (85.2)

38 (48.7)

20 (38.5)

Surgery, n (%)

?

?

?

?

Total thyroidectomy

23 (85.2)

68 (87.2)

44 (84.6)

0.065

Near total thyroidectomy

4 (14.8)

10 (12.8)

8 (15.4)

Neck dissection, n (%)

?

?

?

?

No

3 (11.1)

25 (32.1)

15 (28.8)

0.047

Yes

24 (88.9)

53 (67.9)

37 (71.2)

Central

13 (54.2)

30 (56.6)

18 (48.6)

Lateral

11 (45.8)

23 (43.4)

19 (51.4)

Adjuvant RAI therapy, n (%)

?

?

?

?

No

1 (3.7)

7 (9.0)

2 (3.8)

0.460

Yes

26 (96.3)

71 (91.0)

50 (96.2)

30 mCi

0

4 (5.6)

1 (2.0)

100 mCi

7 (27.0)

20 (28.2)

19 (38.0)

150 mCi

14 (53.8)

36 (50.7)

20 (40.0)

200 mCi

5 (19.2)

11 (15.5)

10 (20.0)

N number, DTC differentiated thyroid cancers, SD standrad deviation, M male, F female, T tumor, N node, M metastasis, LVSI lymphovascular space invasion, RAI radioactive iodine, mCi millicurie

All patients underwent total or near total thyroidectomy without any difference between children and adults. However, because of palpable or radiological visible lymph nodes, the neck dissection was attempted more in children than those in other age groups (88.9 % vs. 67.9 % vs. 71.2 %) P?=?0.047. Among 157 patients, 147 (93.6 %) patients were given adjuvant RAI ablation. Median time to RAI ablation was 8.2 weeks (6.8-16.6) from thyroidectomy and no significant differences in the frequency of adjuvant RAI ablation were observed between the children and adults (P =0.460).

Complications and Toxicities

Post-thyroidectomy complication rates were minimal; however, permanent hypocalcemia was statistically and significantly high in children and young adults (P?=?0.043). Overall, RAI ablation was tolerated well without any grade 3 or 4 side effects; however, acute and late (any grade) complications were seen significantly higher in children and young adults (P?=?0.041) Table 2. [ Table Omitted - see PDF ]

Table 2

Comparative analysis of complications of surgery and toxicities of radioactive iodine ablation in our cohort

Toxicity

Children Age below 18 years

Young adults Age 19-25 years

Adults Age26-30 years

P value

(n?=?27)

(n =78)

(n =52)

Thyroidectomy, n (%)

Hypocalcemia

5 (18.5)

11 (14.1)

8 (15.4)

0.064

Transient

4 (80.0)

9 (81.8)

7 (87.5)

Permanent

1 (20.0)

2 (18.2)

1 (12.5)

0.043

Recurrent laryngeal nerve damage

1 (3.7)

1 (1.3)

1 (1.9)

0.072

RAI ablation, n (%)

Acute:

16 (59.3)

36 (46.1)

18 (34.6)

0.041

Sialadenitis

5 (31.3)

12 (33.3)

6 (33.3)

0.071

Acute sickness (nausea, vomiting)

4 (25.0)

17 (47.2)

10 (55.5)

0.042

Neck pain

7 (43.7)

7 (19.5)

2 (11.1)

0.001

RAI ablation, n (%)

Late:

2 (7.4)

3 (3.8)

1 (1.9)

0.034

Sicca syndrome

1 (50.0)

3 (100)

0

Nasolacrimal duct obstruction

1 (50.0)

0

1 (100)

Second malignancy

0

0

0

Infertility

0

0

0

Lung fibrosis

0

0

0

RAI Radioactive iodine, n number

Treatment outcomes

Median follow-up period was 6.2 years (range: 2.0-10). For whole cohort, the 10-year LRC and DMC rates were 87.2 and 84.2 % respectively. The 10-year LRC and DMC rates were significantly lower in children (75.3 and 64.7 % respectively) than those young adults and adults. Total 18 LRs (11.5 %) were observed; 6/27 in children, 9/78 in young adults and 3/52 in adults (P?=?0.032) Table 3. The LRs were salvaged by surgery; lateral neck dissection (13 patients); completion thyroidectomy (4 patients) and excision (2 patients) followed by RAI ablation (16 patients). Similarly, total 24 DM (15.3 %) were observed; 10/27 in children, 9/78 in young adults and 5/52 in adults (P?=?0.002). DMs were salvaged by RAI ablation and palliative irradiation for bony lesion (one patient). [ Table Omitted - see PDF ]

Table 3

Pattern of failure after thyroidectomy and radioactive iodine therapy in children and adults with differentiated thyroid cancer

Failures

Children Age below 18 years (n?=?27)

Young adults Age 19-25 years (n?=?78)

Adults Age 26-30 years (n =52)

P value

Locoregional, n (%)

6 (22.2)

9 (11.5)

3 (5.8)

0.032

Thyroid bed

1 (16.7)

2 (22.2)

0

Lymph nodes

5 (83.3)

7 (77.8)

3 (100)

Distant, n (%)

10 (37.0)

9 (10.3)

5 (9.6)

0.002

Lungs

10 (100)

9 (100)

4 (80.0)

Bones

-

-

1 (20.0)

Locoregional?+?distant

4 (14.8)

4 (5.1)

2 (3.8)

0.035

10 year LRC rate

75.3%

87.3 %

93.2 %

0.001

10 year DMC rate

64.7 %

84.8 %

94.2 %

0.0001

10 year OS rate

92.3 %

96.2 %

100 %

0.079

n number, LRC locoregional control, DMC distant metastasis control, OS overall survival

The 10-year DFS rates were 67.3 % in children, 82.4 % in young adults and 90.1 % in adults (p?=?0.021) Fig. 1. There was no statistically significant difference in 10-year OS rates among all age groups (P?=?0.075). [ Table Omitted - see PDF ]

Figure. 1

Kaplan-Meier curves of disease free survival in age groups?<?18 years, 19-25 years and 26-30 years

Discussion

Due to rarity of DTC in children and young adults, few major controversies regarding aggressiveness of clinical behavior and optimal treatment still persist [8]. In present study, some unusual observations related to histopathological features were observed, which are in contradiction to reported literature.

Firstly, no statistically significant difference in primary tumor volumes or presence of extrathyroidal extension (ETE) was observed between the children and adults. Previous studies have hypothesized that the tumor volumes tend to be relatively larger in children when compared to adults, probably attributed to smaller thyroid volume in children, thus higher chances of ETE and capsular invasion [3-5, 9, 10]. Similar to our results, few studies have also reported no correlation between tumor volumes and pediatric population [11-13]. However, no difference in tumor volumes or ETE among children and adults can be criticized for relatively few pre-pubertal children in our cohort. Secondly, in contrast to children, multifocality was found more prevalent in our adult cohort, which is a reasonable argument against wide practice of total thyroidectomy as primary surgical approach in children [14, 15] Thirdly, male gender was predominant in our pediatric cohort, which is likely attributed to hormonal changes during pre-puberty and puberty [16].

Further, it was also clear that larger percentage of children underwent elective neck dissections mainly because of increased frequency of clinical or radiological cervical lymphadenopathy at the time of diagnosis. Similarly, treatment related complications were observed more in children. Large percentage of permanent hypocalcemia supports the notion of less aggressive surgery (lobectomy or hemi-thyroidectomy) for primary tumor in children, to decrease the risk of surgical complications [17, 18]. Similarly, the children experienced relatively more acute and late (any grade) RAI induced complications in our cohort. However, no RAI ablation induced second primary malignancy (SPM), lung fibrosis or infertility was observed. Possible explanation could be the short follow-up, and given lower cumulative doses of RAI in our cohort [5, 19].

In contrast to previously published data, children in our cohort experienced relatively higher all-sites recurrence rates, thus lower 10-year DFS rate (67.3 %) after extensive treatment [4, 5, 7, 9, 20, 21] which is attributed to our ATA high risk (85.2 %) pediatric cohort.

There were few limitations of our study. Firstly, since more children were rendered to neck dissections, there was a possible selection bias when it came to the number of lymph nodes found to harbor metastasis. Secondly, TSH suppression therapy complications including effects on child growth, osteoporosis and cardiovascular diseases were not studied, as children are still in growing phase, and TSH suppression therapy theoretically may affect their final height [22]. Thirdly, we did not look into molecular patterns in childhood DTC. Bongarzone I et al. initially reported that the frequency of 'Rearranged during Transcription' (RET) and 'neurotrophic tyrosine kinase receptor-1' (NTRK1) oncogenic activation is significantly higher in childhood DTC, thus contributing to childhood DTC carcinogenesis [23]. Besides RET/NTRK1, over-expression of proto-oncogenes 'MET', and 'vascular endothelial growth factor' (VEGF) have been found to cause high recurrence rate in children [24].

Conclusions

In conclusion, DTC in Saudi children is far more aggressive entity in nature as compared to adults. Children are at higher risk of treatment (thyroidectomy and RAI) related complications as compared to adults. Lower LRC, DMC and DFS rates in children after extensive therapy of thyroidectomy, neck dissection followed by RAI, TSH suppression warrants further multi-institutional studies.

Declarations

Acknowledgement

We are thankful to Laura Stanciu Gabriella for her efforts in the revision of manuscript and drafting.

Interest of conflict

All authors declare no potential conflict of interest. No grant or funds have been received for this study.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

KQ and MT participated in the design of the study and performed the statistical analysis. MA, YB, NJ and KR collected the data and drafted the manuscript. WS carried out the histopathology data collection and edited the manuscript. MT conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.

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