Predicting Outcomes in Sporadic and Hereditary Medullary Thyroid Carcinoma over Two Decades

Abstract

Background: Medullary thyroid cancer (MTC) can be associated with significant morbidity and mortality in advanced cases. Hence, we aimed to identify factors at the time of MTC surgery that predict overall survival (OS), disease-specific survival (DSS), locoregional recurrence/persistence (LR), and distant metastases (DM). Methods: We performed a retrospective study of clinicopathologic, radiological, and laboratory data in MTC patients who underwent thyroidectomy at Mayo Clinic from January 1995 to December 2015. Results: We identified 163 patients (mean age 48.4 years, 48% males), 102 with sporadic MTC and 61 with hereditary disease (n = 46 multiple endocrine neoplasia [MEN] 2A, n = 3 MEN 2B, n = 12 familial MTC) with a median follow-up time of 5.5 years. On univariate analysis, age >55 years, male sex, DM at the time of surgery (M1), lateral neck lymph node (LN) involvement (N1b), gross extrathyroidal extension (ETE), American Joint Committee on Cancer (AJCC) stage 3/4, tumor size (T) 3/4, tumor size, and postoperative calcitonin (Ctn) and carcinoembryonic antigen (CEA) were significant predictors of worse OS and DSS. On multivariable analysis, both gross ETE (hazard ratio [HR] 4.62, 6.58) and M1 (HR 5.11, 10.45) remained significant predictors of worse OS as well as DSS, while age >55 years (HR 3.21), male sex (HR 2.42), and postoperative Ctn (HR 1.002 for every 100 pg/mL increase) were significant only for worse OS. On univariate analysis, male sex, M1, N1b, gross ETE, stage 3/4, T 3/4, tumor size, number of LNs involved, and postoperative Ctn were significant predictors of LR and DM; age >55 years was additionally significant for DM. On multivariable analysis, gross ETE (HR 3.16, 5.93) and N1b (HR 4.31, 4.64) remained significant predictors of LR and DM; ratio of resected/involved LN (HR 10.91) was additionally predictive for LR and postoperative Ctn (HR 1.003 for every 100 pg/mL increase) for DM. Conclusions: Disease burden at initial surgery, especially gross ETE, lateral neck LN involvement, and DM, as well as the biochemical response to surgery appear to be more important than demographic factors in terms of MTC prognosis. These findings highlight the importance of rigorous perioperative assessment to better predict MTC outcomes.

Keywords: cancer recurrence; metastasis; mortality; survival; thyroid cancer; thyroidectomy.

FIG. 1.

(a) Overall survival comparing MTC patients with AJCC TNM stages 3 and 4 vs. 1 and 2 (p = 0.0007). (b) Disease-specific survival comparing MTC patients with AJCC TNM stages 3 and 4 vs. 1 and 2 (p = 0.005). AJCC, American Joint Committee on Cancer; MTC, medullary thyroid cancer.

FIG. 2.

Overall survival comparing MTC patients with postoperative Ctn >1000 pg/mL vs. 10–5000 pg/mL vs. 0–10 pg/mL (p = 0.008). Ctn, calcitonin.

FIG. 3.

(a) Disease-specific survival comparing MTC patients with distant metastases (M1) vs. those without distant metastases (M0) at initial surgery (p < 0.0001). (b) Disease-specific survival comparing MTC patients with gross ETE vs. those without gross ETE at initial surgery (p < 0.0001). ETE, extrathyroidal extension.