ETJ advanced medullary thyroid cancer collection

 

Medullary and other forms of advanced thyroid cancer remain therapeutically challenging for the clinician, and novel molecularly-targeted systemic treatments are becoming the mainstay of management for those patients with disseminated disease. This topic collection focussed on recent developments in the management of people with these advanced thyroid cancers.

If you are interested in contributing an original research article to this collection, please submit your article proposal to etj@bioscientifica.com.

 

Explore all European Thyroid Journal Special Collections

 

Advanced medullary thyroid cancer

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Juan Antonio Vallejo Casas Department of Nuclear Medicine (UGC), Maimónides Institute of Biomedical Research of Córdoba (IMIBIC), Reina Sofía University Hospital, University of Córdoba, Córdoba, Spain

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Marcel Sambo Department of Endocrinology, Gregorio Marañón University Hospital, Madrid, Spain

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Carlos López López Department of Medical Oncology, Marqués de Valdecilla University Hospital, IDIVAL, Santander, Spain

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Manuel Durán-Poveda Department of General and Digestive Surgery, Rey Juan Carlos University Hospital, Madrid, Spain

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Julio Rodríguez-Villanueva García Oncology Business Group – EISAI Farmacéutica SA, Madrid, Spain

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Rita Joana Santos Department of Endocrinology, Francisco Gentil Portuguese Institute of Oncology of Lisbon, Lisbon, Portugal

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Marta Llanos Department of Medical Oncology, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain

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Elena Navarro-González Department of Endocrinology, Virgen del Rocío University Hospital, Seville, Spain

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Javier Aller Department of Endocrinology, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain

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Virginia Pubul Department of Nuclear Medicine, University Hospital and Health Research Institute of Santiago de Compostela, Santiago de Compostela, Spain

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Sonsoles Guadalix Department of Endocrinology and Nutrition, Hospital Universitario 12 de Octubre, Madrid, Spain

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Guillermo Crespo Department of Medical Oncology, Burgos University Hospital, Burgos, Spain

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Cintia González Department of Endocrinology, Santa Creu i Sant Pau University Hospital, CIBER-BBN, Barcelona, Spain

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Carles Zafón Department of Endocrinology and Nutrition, Vall Hebron University Hospital and Autonomous University of Barcelona (UAB), Barcelona, Spain

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Miguel Navarro Department of Medical Oncology, University Hospital of Salamanca, Salamanca, Spain

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Javier Santamaría-Sandi Department of Endocrinology, Cruces University Hospital, Vizcaya, Spain

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Ángel Segura Medical Oncology Unit, La Fe University Hospital, Valencia, Spain

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Pablo Gajate Department of Medical Oncology, Ramon y Cajal University Hospital, Madrid, Spain

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Marcelino Gómez-Balaguer Department of Endocrinology, Doctor Peset University Hospital, Valencia, Spain

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Javier Valdivia Department of Oncology, University Hospital Centre Virgen de las Nieves, Granada, Spain

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Manel Puig-Domingo Endocrine and Nutrition Service, Health Sciences Research Institute and University Hospital Germans Trias i Pujol, Badalona, Spain

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Juan Carlos Galofré Department of Endocrinology, Clínica Universidad de Navarra, University of Navarra, Lisbon, Spain

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Beatriz Castelo Department of Medical Oncology, La Paz University Hospital, Madrid, Spain

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María José Villanueva Department of Medical Oncology, Alvaro Cunqueiro University Hospital Complex, University of Vigo, Vigo, Spain

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Iñaki Argüelles Department of Endocrinology and Nutrition, Son Espases University Hospital, Palma de Mallorca, Spain

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Lorenzo Orcajo-Rincón Oncology Business Group – EISAI Farmacéutica SA, Madrid, Spain

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Background

Up to 30% of differentiated thyroid cancer (DTC) will develop advanced-stage disease (aDTC) with reduced overall survival (OS).

Objective

The aim of this study is to characterize initial diagnosis of aDTC, its therapeutic management, and prognosis in Spain and Portugal.

Methods

A multicentre, longitudinal, retrospective study of adult patients diagnosed with aDTC in the Iberian Peninsula was conducted between January 2007 and December 2012. Analyses of baseline characteristics and results of initial treatments, relapse- or progression-free survival ((RP)FS) from first DTC diagnosis, OS, and prognostic factors impacting the evolution of advanced disease were evaluated.

Results

Two hundred and thirteen patients (median age: 63 years; 57% female) were eligible from 23 hospitals. Advanced disease presented at first diagnosis (de novo aDTC) included 54% of patients, while 46% had relapsed from early disease (recurrent/progressive eDTC). At initial stage, most patients received surgery (98%) and/or radioiodine (RAI) (89%), with no differences seen between median OS (95% CI) (10.4 (7.3–15.3) years) and median disease-specific-survival (95% CI) (11.1 (8.7–16.2) years; log-rank test P = 0.4737). Age at diagnosis being <55 years was associated with a lower risk of death (Wald chi-square (Wc-s) P < 0.0001), while a poor response to RAI to a higher risk of death ((Wc-s) P < 0.05). In the eDTC cohort, median (RP)FS (95% CI) was of 1.7 (1.0–2.0) years after RAI, with R0/R1 surgeries being the only common significant favourable factor for longer (RP)FS and time to aDTC ((Wc-s) P < 0.05).

Conclusion

Identification of early treatment-dependent prognostic factors for an unfavourable course of advanced disease is possible. An intensified therapeutic attitude may reverse this trend and should be considered in poor-performing patients. Prospective studies are required to confirm these findings.

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Jihwan Yoo Department of Neurosurgery, Brain Tumor Center, Gangnam Severance Hospital, Seoul, Republic of Korea
College of Medicine, Yonsei University, Seoul, Republic of Korea

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Hee Jun Kim Department of Surgery, CHA Ilsan Medical Center, Cha University School of Medicine, Goyang-si, Republic of Korea

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Seok Mo Kim Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, Republic of Korea

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Hun Ho Park Department of Neurosurgery, Brain Tumor Center, Gangnam Severance Hospital, Seoul, Republic of Korea

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Introduction

Brain metastasis in differentiated thyroid cancer (DTC) is rare (frequency < 1%) and has a poor prognosis. Treatment strategies for brain metastasis are not well established.

Objectives

We conducted a retrospective analysis to identify predictive factors for patient outcomes and verify surgical indications for patients with brain metastasis and DTC.

Methods

The study included 34 patients with pathologically confirmed DTC with brain metastasis from March 2008 to November 2020. The associations between overall survival (OS) and clinical factors were evaluated. Cox regression analysis was used to determine the relationship between clinical factors and OS. To assess the survival benefit of craniotomy, Kaplan–Meier survival analysis was performed for each variable whose statistical significance was determined by Cox regression analysis.

Results

The median OS of the entire patient sample was 11.4 months. Survival was affected by the presence of lung metastasis (P = 0.033) and the number of brain metastases (n  > 3) (P = 0.039). Only the subgroup with the number of brain metastases ≤3 showed statistical significance in the subgroup analysis of survival benefit following craniotomy (P = 0.048).

Conclusions

The number of brain metastases and the existence of lung metastasis were regarded more essential than other clinical factors in patients with DTC in this study. Furthermore, craniotomies indicated a survival benefit only when the number of brain metastases was ≤3. This finding could be beneficial in determining surgical indications in thyroid cancer with brain metastasis.

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Ségolène Hescot Department of Drug Development and Innovation (D3i), Institut Curie, Paris, France

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Julien Masliah-Planchon Department of Genetics, Institut Curie, Paris, France

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Pauline du Rusquec Department of Drug Development and Innovation (D3i), Institut Curie, Paris, France

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Célia Dupain Department of Drug Development and Innovation (D3i), Institut Curie, Paris, France

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Maud Kamal Department of Drug Development and Innovation (D3i), Institut Curie, Paris, France

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Vincent Servois Department of Radiology, Institut Curie, Paris, France

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Ivan Bieche Department of Genetics, Institut Curie, Paris, France

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Junyu Tong Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China

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Maomei Ruan Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China
Department of Nuclear Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, People’s Republic of China

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Yuchen Jin Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China

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Hao Fu Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China

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Lin Cheng Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China

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Qiong Luo Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China

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Zhiyan Liu Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China
Department of Pathology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China

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Zhongwei Lv Department of Nuclear Medicine, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China

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Libo Chen Department of Nuclear Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, People’s Republic of China

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Poorly differentiated thyroid carcinoma (PDTC) is a rare thyroid carcinoma originating from follicular epithelial cells. No explicit consensus can be achieved to date due to sparse clinical data, potentially compromising the outcomes of patients. In this comprehensive review from a clinician’s perspective, the epidemiology and prognosis are described, diagnosis based on manifestations, pathology, and medical imaging are discussed, and both traditional and emerging therapeutics are addressed as well. Turin consensus remains the mainstay diagnostic criteria for PDTC, and individualized assessments are decisive for treatment option. The prognosis is optimal if complete resection is performed at early stage but dismal in nearly half of patients with locally advanced and/or distant metastatic diseases, in which adjuvant therapies such as 131I therapy, external beam radiation therapy, and chemotherapy should be incorporated. Emerging therapeutics including molecular targeted therapy, differentiation therapy, and immunotherapy deserve further investigations to improve the prognosis of PDTC patients with advanced disease.

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Stéphane Bardet Department of Nuclear Medicine and Thyroid Unit, Centre François Baclesse, Caen, France

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Renaud Ciappuccini Department of Nuclear Medicine and Thyroid Unit, Centre François Baclesse, Caen, France

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Livia Lamartina Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy, Villejuif, France

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Sophie Leboulleux Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy, Villejuif, France

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Introduction

Serum calcitonin (CT) and carcinoembryonic antigen (CEA) are valuable tumour markers in patients with medullary thyroid carcinoma (MTC). Both markers most often evolve in parallel after treatment. Selpercatinib (LOXO-292) is a highly selective RET kinase inhibitor indicated in advanced RET-mutant MTC patients.

Cases presentation

In this study, we report two observations of RET-mutant progressive metastatic and symptomatic MTC patients who were treated with selpercatinib. Patient 1, a 61-year-old man, presented dyspnoea and diarrhoea at selpercatinib initiation with large neck lymph nodes and lung metastases. Patient 2, a 76-year-old man, had acute discomfort with flush and diarrhoea, with small but diffuse bone and liver disease. Both patients had an objective tumour response with rapid clinical improvement and RECIST 1.1 response (−90%) in patient 1. A rapid dramatic decrease in CT level was observed in both patients (−99% in both patients), while CEA levels gradually and sustainably increased after selpercatinib initiation (+207% at cycle 15 in patient 1 and + 835% at cycle 14 in patient 2). In both patients, 18FDG PET/CT did not show any abnormal uptake that could explain the CEA increase. Colonoscopy and oesogastric fibroscopy showed colonic polyposis with mild oesophagitis and gastritis in patient 1 and were normal in patient 2.

Conclusion

These observations show an unusual and lasting increase in serum CEA in two MTC patients who exhibited an objective tumour response to selpercatinib. The mechanism behind this unexpected rise in CEA level remains unknown. The frequency of this evolving profile will be determined in further phase III studies.

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Zhen Gao The First Department of Oncology, Hebei General Hospital, Shijiazhuang, China

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Hongtao Zhang The First Department of Oncology, Hebei General Hospital, Shijiazhuang, China

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Lijuan Zhang The First Department of Oncology, Hebei General Hospital, Shijiazhuang, China

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Huimin Yu The First Department of Oncology, Hebei General Hospital, Shijiazhuang, China

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Xuemin Di The First Department of Oncology, Hebei General Hospital, Shijiazhuang, China

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Zeyang Wang The First Department of Oncology, Hebei General Hospital, Shijiazhuang, China

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Zezhou Liu The First Department of Oncology, Hebei General Hospital, Shijiazhuang, China

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Aixia Sui The First Department of Oncology, Hebei General Hospital, Shijiazhuang, China

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Juan Wang The First Department of Oncology, Hebei General Hospital, Shijiazhuang, China

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Gaofeng Shi Department of Radiology, The 4th Affiliated Hospital of Hebei Medical University, Shijiazhuang, China

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Background: Papillary thyroid carcinoma (PTC) is typically treated with surgical resection, even in recurrent cases. However, some cases of recurrent PTC are refractory to the conventionally used locoregional radiotherapy and resection methods. <sup>125</sup>I seed permanent brachytherapy has emerged as a promising alternative for such PTCs, but no effective brachytherapy protocol has been reported for tumors with a huge volume, liquefaction, necrosis, and skin invasion. Case Presentation: A 47-year-old man presented with recurrence 8 years after 2 thyroidectomy procedures for PTC and recurrent PTC. The tumor measured 6 × 7 × 8 cm<sup>3</sup> and exhibited liquefaction, necrosis, and skin invasion. The patient was treated at our hospital from December 2017 to November 2018. He received one round of <sup>125</sup>I seed temporary brachytherapy and 4 rounds of <sup>125</sup>I seed permanent implantation. The activity of the seeds was 0.3–3.0 mCi, and the total dose delivered to the tumor was 145 Gy. The recurrent tumor was successfully removed by <sup>125</sup>I seed brachytherapy guided with a 3D-printed template and ultrasound and CT scanning. The refractory tumor healed uneventfully after <sup>125</sup>I seed brachytherapy without recurrence over the 25-month follow-up. Conclusions: To the best of our knowledge, this is the first reported case of a large thyroid carcinoma that was effectively treated by 3D-printed template-guided <sup>125</sup>I seed brachytherapy.

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Camille Buffet Department of Thyroid Pathologies and Endocrine Tumors, AP-HP, Pitié-Salpêtrière Hospital, Groupe de Recherche Clinique n°16 Tumeurs Thyroïdiennes, Sorbonne Université, Paris, France
UMR9019, Genome Integrity and Cancers, CNRS, Villejuif, France

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Sophie Leboulleux Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Institut, Villejuif, France

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Françoise Kraeber-Bodéré Nuclear Medicine Department, Université de Nantes, CHU de Nantes, CNRS, Inserm, CRCINA, Nantes, France
CHU Nantes/ICO, Saint-Herblain, France

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Caroline Bodet-Milin Nuclear Medicine Department, Université de Nantes, CHU de Nantes, CNRS, Inserm, CRCINA, Nantes, France
CHU Nantes/ICO, Saint-Herblain, France

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Laure Cabanes Department of Cardiology, APHP, Cochin Hospital, Paris, France
Université de Paris, Paris, France

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Anthony Dohan Radiology Department, Université de Paris, Paris, France
Department of Radiology, AP-HP, Hôpital Cochin, Paris, France

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Pascal Leprince Department of Thoracic and Cardiovascular Surgery, Sorbonne Université, AP-HP, Pitié-Salpêtrière Hospital, Paris, France

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Martin Schlumberger UMR9019, Genome Integrity and Cancers, CNRS, Villejuif, France
Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy Institute, Villejuif, France

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Olivier Huillard Université de Paris, Sorbonne Paris Cité, Paris, France
Department of Medical Oncology, AP-HP, Hôpital Cochin, Paris, France

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Lionel Groussin INSERM Unité 1016, CNRS UMR 8104, Institut Cochin, Paris, France
Université de Paris, Paris, France
Department of Endocrinology, AP-HP, Hôpital Cochin, Paris, France

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Background: Cardiac metastases from thyroid cancers are uncommon with a poor prognosis. There is a lack of long-term follow-up studies. Cases: We report 2 cases of cardiac metastasis from medullary thyroid cancer (MTC). Both patients presented limited metastatic disease apart from a cardiac metastasis. The initial diagnosis was challenging and was facilitated by functional imaging with an immuno-PET-CT using an anti-CEA bispecific antibody and a <sup>68</sup>Ga-labeled peptide. Both patients were treated with the multitarget kinase inhibitor vandetanib with prolonged stability. The first patient was alive at the last follow-up, 14 years after the diagnosis of cardiac metastasis. The second patient required surgical excision of the cardiac mass because of disease progression under vandetanib. Conclusion: These cases illustrate long-term survival and effectiveness of clinical management of 2 patients who developed cardiac metastases from MTC, in the current era of personalized medicine with targeted therapy.

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Tim Brandenburg Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Center at West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
Endocrine Tumour Center at West German Cancer Center, Member of ENDO-ERN and EURACAN, University Hospital Essen, University of Duisburg-Essen, Essen, Germany

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Philipp Muchalla Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Center at West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
Endocrine Tumour Center at West German Cancer Center, Member of ENDO-ERN and EURACAN, University Hospital Essen, University of Duisburg-Essen, Essen, Germany

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Sarah Theurer Endocrine Tumour Center at West German Cancer Center, Member of ENDO-ERN and EURACAN, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
University Duisburg-Essen, Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany

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Kurt Werner Schmid Endocrine Tumour Center at West German Cancer Center, Member of ENDO-ERN and EURACAN, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
University Duisburg-Essen, Institute of Pathology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany

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Dagmar Führer Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Center at West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
Endocrine Tumour Center at West German Cancer Center, Member of ENDO-ERN and EURACAN, University Hospital Essen, University of Duisburg-Essen, Essen, Germany

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Introduction: Primary squamous cell carcinoma (PSCC) of the thyroid is an exceptionally rare malignancy accounting for <1% of all primary thyroid cancers. Therapy is multimodal including surgery, radiotherapy, and chemotherapy but with no consensus for management and therapy. Here, we describe a case of a male patient who presented with a BRAF V600E-mutated PSCC of the thyroid gland showing response to combined dabrafenib and trametinib therapy over a period of >12 months. Case Presentation: A 78-year-old male patient presented with a 3-week history of dysphonia and dyspnoea. Laryngoscopy revealed a mechanical obstruction by a right-sided, subglottical mass, which on cervical ultrasound was highly suggestive of anaplastic thyroid carcinoma. Additional workup including esophagogastroduodenoscopy showed compression of the oesophagus but no oesophageal infiltration by the tumour. Immunohistochemistry displayed CK19-positive cells indicating epithelial origin of the tumour. CK5/6 and P40 immunohistochemistry confirmed the morphological impression of squamous cell differentiation while staining with thyroid markers TTF-1 and TPO was negative and PAX8 showed a nuclear positive signal. Based on immunohistopathology, presence of TP53 and BRAF V600E mutations, and exclusion of metastatic squamous cell carcinoma of other origin, the diagnosis of a PSCC of the thyroid was established. As an individualized treatment concept, we decided to advocate combined BRAF V600E targeting by the multikinase inhibitors dabrafenib and trametinib. This led to drastic improvement in patient’s quality of life without severe side effects over a period of >12 months. Conclusion: In this case, molecular diagnosis allowed a highly individualized treatment concept with combined dabrafenib and trametinib therapy.

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Fabio Maino Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Cristina Dalmiglio Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Nicoletta Benenati Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Michele Campanile Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Tania Pilli Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Raffaella Forleo Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Lucia Brilli Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Cristina Ciuoli Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Silvia Cantara Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Marco Capezzone Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Alessandra Cartocci Department of Medical Biotechnologies, University of Siena, Siena, Italy

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Furio Pacini Humanitas Clinical Institute, Humanitas University, Rozzano, Italy

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Maria Grazia Castagna Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy

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Introduction: Association between hypercalcitoninemia and pathological conditions such as autoimmune thyroiditis (AIT) or differentiated thyroid carcinoma (DTC) has been addressed, with conflicting results. We evaluated the prevalence and the clinical relevance of elevated basal serum calcitonin (CT) levels in non-neoplastic (nodular goiter [NG] and AIT) and neoplastic thyroid diseases (DTC). Methods: We retrospectively evaluated 3,250 consecutive patients with thyroid nodular disease who underwent fine-needle aspiration cytology with adequate sample. After exclusion of medullary thyroid cancer (MTC) patients were divided according to the presence/absence of thyroid autoimmunity into NG or nodular autoimmune thyroiditis (N-AIT) and, according to cytological results, in benign or suspicious/malignant nodules. Results: One hundred ninety-seven/3,250 patients (6.0%) showed CT level >10 pg/mL. In 11/3,250 (0.3%) cases, a final histological diagnosis of MTC was made, while the remaining 186/3,250 patients (5.7%) had non-MTC-related hypercalcitoninemia (CT > 10 pg/mL). According to cytological diagnosis, the rate of hypercalcitoninemia was similar in class II and class V–VI groups (5.4 vs. 6.9%, p = 0.4). The occurrence of hypercalcitoninemia was significantly higher in patients with NG (166/2,634 [6.3%]) than in patients with N-AIT (20/605 [3.3%]) (p = 0.004). However, after matching by sex, no difference was found between the 2 groups (NG and N-AIT). These results were confirmed in 598 patients submitted to surgery. Conclusions: AIT and DTC seem not to affect serum CT levels in patients with thyroid nodules. Therefore, hypercalcitoninemia, in these patients, should be submitted to the same diagnostic workup than patients without AIT or DTC.

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Marta Di Stefano Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy

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Carla Colombo Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy

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Simone De Leo Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy

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Michela Perrino Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy

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Mauro Viganò Division of Hepatology, San Giuseppe Hospital Multimedica IRCCS, Milan, Italy

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Luca Persani Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
Department of Clinical Sciences and Community Health, Milan, Italy

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Laura Fugazzola Division of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy

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Introduction: Lenvatinib (LEN) is a multitarget tyrosine kinase inhibitor currently used for advanced, radioiodine refractory differentiated thyroid cancer (RAI-R DTC). Among adverse events (AEs), nausea, vomiting, and decreased appetite have been frequently described. We aimed to evaluate the prevalence, the clinical presentation, and the effectiveness of conservative treatment of gallbladder disorders in a consecutive series of patient treated with LEN. Methods: Patients with RAI-R DTC experiencing clinical symptoms suggestive for gallbladder disorders during LEN treatment were evaluated with laboratory investigations and contrast-enhanced abdominal computed tomography (CT) and ultrasound scan (US). Results: After a median time of 2 months from the start of treatment, 5/13 patients (38.4%) complained of gastrointestinal symptoms, with increased biliary enzymes levels, especially γGT, and CT/US suggestive of acute cholecystitis (AC). The onset of symptoms and the peak of γGT levels frequently corresponded to the highest reduction in body weight during the first months of treatment. All patients were treated with supportive care and, when appropriate, with ursodeoxycholic acid; in 4 patients, LEN dose reduction or short interruption was needed, too. Conclusions: In patients with RAI-R DTC treated with LEN, a high prevalence of AC in the first months of treatment was documented. Mainly due to the low specificity of symptoms such as anorexia, nausea, and vomiting, this AE is likely to be frequently misdiagnosed. The onset of the disease was associated to the weight loss observed during the first months of treatment and contributes to further decrease in body weight. Therefore, particularly during the first months of treatment, or at any time of huge reduction of body weight, monitoring of γGT and US is crucial for prompt diagnosis and treatment. Conservative medical treatment and LEN dosage titration, together with dietary and rehabilitative supports, can limit or avoid the need for drug withdrawal and cholecystectomy.

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