title: Papillary thyroid carcinomas with cervical lymph node metastases can be stratified into clinically relevant prognostic categories using oncogenic BRAF, the number of nodal metastases, and extra-nodal extension.
abstract: BACKGROUND
  Papillary thyroid carcinoma (PTC) patients presenting with cervical lymph nodes (LN) metastases (M) have a variable outcome. The objective of this study is to assess the value of meticulous histopathologic examination and genotyping in stratifying these patients into clinically relevant prognostic subgroups.
  
  
  METHODS
  This was a retrospective clinical and histopathological review of PTC patients with lymph node metastases at presentation identified between 1980 and 2002 in a single institution. Primary tumors from patients who later recurred were matched to a group of patients who did not recur and subjected to mass spectrometry genotyping encompassing the most significant oncogenes in thyroid carcinomas.
  
  
  RESULTS
  There were 246 patients who satisfied the inclusion criteria. The median follow-up was 10.8 years. The presence of >3 metastatic nodes was an independent predictor of decreased recurrence free survival (p=0.03). In patients <45 years, none of 45 with 1-2 metastatic LN recurred, including 26 patients followed for a median of 13 years without radioactive iodine (RAI) therapy. BRAF mutations were found in 28 (78%) of 36 genotyped tumors. Combined positivity for BRAF and extra-nodal extension was much stronger in predicting disease specific survival (DSS) (p=0.004) than the single analysis of BRAF (p=0.12) or extra-nodal extension (p=0.02).
  
  
  CONCLUSIONS
  (i) The number of metastatic LN is an independent predictor of recurrence in all age groups and identifies a subset of young patients with excellent prognosis who may not benefit from RAI therapy. (ii) Combined positivity for BRAF and extra-nodal extension has additive prognostic value in predicting DSS. (iii) Classification systems that assign the same magnitude of risk for recurrence or death to all patients with N1 disease should be revisited.
authors.affiliation: Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA.
authors.forename: Julio
authors.initials: J
authors.lastname: Ricarte-Filho
authors.forename: Ian
authors.initials: I
authors.lastname: Ganly
authors.forename: Michael
authors.initials: M
authors.lastname: Rivera
authors.forename: Nora
authors.initials: N
authors.lastname: Katabi
authors.forename: Weimin
authors.initials: W
authors.lastname: Fu
authors.forename: Ashok
authors.initials: A
authors.lastname: Shaha
authors.forename: R Michael
authors.initials: RM
authors.lastname: Tuttle
authors.forename: James A
authors.initials: JA
authors.lastname: Fagin
authors.forename: Ronald
authors.initials: R
authors.lastname: Ghossein
mesh_terms: D002277:Carcinoma; D002291:Carcinoma, Papillary; D005260:Female; D005500:Follow-Up Studies; D005838:Genotype; D006801:Humans; D007457:Iodine Radioisotopes; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009154:Mutation / Q000235:genetics*; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D011237:Predictive Value of Tests; D011379:Prognosis; D048493:Proto-Oncogene Proteins B-raf / Q000235:genetics*; D012189:Retrospective Studies; D015996:Survival Rate; D000077273:Thyroid Cancer, Papillary; D013964:Thyroid Neoplasms / Q000175:diagnosis / Q000235:genetics* / Q000473:pathology*
chemical_list: D007457:Iodine Radioisotopes; C482119:BRAF protein, human; D048493:Proto-Oncogene Proteins B-raf