THYROID
Volume 10, Number 11, 2000
Mary Ann Liebert, Inc.
Anaplastic Changes Associated with p53 Gene Mutation
Differentiated Thyroid Carcinoma After Insufficient
Radioactive Iodine (131l) Therapy
Nobuko
Sera,1 Kiyoto Ashizawa,1 Takao Ando,1 Akane Ide,1 Yasuyo Abe,1 Toshiro Usa,1
Eri Ejima,1 Tomayoshi Hayashi,2 Isao Shimokawa,3 and Katsumi Eguchi1
Tan
in
Tominaga,1
Thirty-two patients with differentiated thyroid carcinomas with distant metastasis were examined using a ra¬
dioactive iodine (131I) tracer dose prior to 131I therapy and followed up for 10 years or until death (whichever
occurred first). Nineteen patients who received 131I therapy had an accumulation of 131I in the métastases (group
I) and 15 of those patients were alive more than 10 years after the first 131I treatment. In contrast, all 13 patients
in whom the métastases did not show accumulation of 131I died within 10 years. Of the latter group, eight pa¬
tients had received 131I therapy (group II), four of whom died with anaplastic changes within 5 years of treat¬
ment. p53 gene mutation was identified by immunohistochemistry in primary thyroid carcinoma tissue from
patients with anaplastic changes that were evident during total thyroidectomy. Five patients did not receive
131I therapy (group III), of whom one, who also had a p53 gene mutation in the original tumor, died with
anaplastic change 10 years after thyroidectomy. Seven patients in group I had p53 gene mutations in their thy¬
roid carcinoma tissues, but none showed anaplastic changes. Our results suggest that 131I therapy may be use¬
ful for patients with distant métastases, with or without p53 gene mutations, which show accumulation of 131I
from tracer and therapeutic doses. In contrast, 131I therapy is apparently not effective in patients who do not
show sufficient accumulation of 131I, but rather, may cause early anaplastic changes with a p53 gene mutation.
Introduction
is extensive literature on the treatment and prog¬
nosis of metastatic thyroid carcinoma. Radioactive io¬
dine (131I) has been used in the therapy of differentiated thyroid carcinoma since 1942 (1). Many publications have
supported the benefit of 131I therapy in metastatic thyroid
carcinoma (2-5), but, conversely, some have not reported any
benefit (6,7). Iodine accumulation in métastases is an important aspect of 131I therapy (8). Severe side-effects of 131I
therapy have only rarely been reported. These include
secondary malignancy (9,10) and, in some patients with
metastatic differentiated thyroid carcinoma, the tumor exhibited anaplastic change (6,11). However, a causal relationship between 131I therapy and such side-effects has not been
established (12). In some cases, anaplastic carcinomas arise
from preexisting well-differentiated thyroid carcinomas (13).
Several studies have shown that p53 gene mutations are
more frequent in poorly differentiated and anaplastic carcinomas than in well-differentiated papillary and follicular
carcinomas (14,15). In this study, we examined the relation-
There
ship between anaplastic change and p53 gene mutation oc¬
curring after 131I therapy.
Material and Methods
Patiente
Between 1965 and 1995, a total of 195 patients were hospitalized in our department at Nagasaki University Hospital, Nagasaki, Japan, for treatment of thyroid carcinoma. In
this study, 32 patients from these 195 patients were selected,
The patients who were selected included those who: (1) had
undergone total thyroidectomy followed by T4 replacement
therapy; and (2) had distant métastases at primary diagnosis. Métastases were surveyed by radiologie workups such
as standard X-rays, computed tomography (CT), scintigraphy, or ultrasonographic scanning, prior to total thyroidectomy. The selected patients were followed up for longer than
10 years from the date of ,31I tracer scintigraphy or until they
died of thyroid carcinoma during this period. Patients with
metastatic thyroid carcinoma but who died of unrelated dis¬
dirsi Department of Internal Medicine, and 2Department of Pathology, Nagasaki University Hospital, Nagasaki, 3First Department of
Pathology, Nagasaki University School of Medicine, Japan.
975
SERA ET AL.
976
Table 1. Patients
Patient
No.
Gender
Age
(yrs)
F
F
F
F
F
F
M
M
F
F
F
F
M
F
F
F
M
F
F
44
19
45
63
70
45
55
37
53
52
66
23
78
63
72
51
35
68
72
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
His.
at ope
Site of
metastasis
Tg
(ng/mL)
Bone
NE
169
NE
NE
NE
NE
899
NE
621,
23700.
Lung
P
F
P
P
P
F
Bone
Bone, Lung
Lung
Lung
Bone, Lung
Bone, Lung
F
F
F
F
P
P
Bone
Bone, Lung
Bone
Lung
Lung
Lung
Lung, Kidney
P
P
Med. LN
F
F
P
Kidney
Med. LN
Hilar LN
P
Group I
of
Dose
J3JJT
(mCi)
uptake
150
150
150
150
150
150
90
150
150
84
148
150
129
126
50
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
-¬
259.
21.
419.
39.
1680.
1532.
180,
0,
120
150
100
150
NE
p53 gene Anaplastic
changes
Outcome mutation
Cause
of
death
His. at
Autopsy
+
A
A
A
A
A
A
A
A
A
A
A
A
A
A
NE
D(4)b
+
+
D(9)
D(9)
+
NE
NE
+
+
NE
+
RF
HF
HF
RF
D(10)
His., histologie diagnosis; Tg, thyroglobuline at administration of 131I tracer dose; P, papillary carcinoma; F, follicular carcinoma; LN,
lymph node; Med. LN, mediastinal LN; +, accumulation of 131I outside thyroid bed by 131uptake posttherapy scans; A, alive; D, deceased; NE,
not examined; RF, respiratory failure; HF, heart failure.
aTherapeutic dose.
bNumbers between parentheses represent the survival period (years) after thyroidectomy.
within the observation period (10 years) were excluded
from this study.
Thirty-two patients who met the above criteria were divided
into three groups. Group I (n 19) was comprised of patients
in whom iodine uptake was observed outside the thyroid bed
after the 131I tracer dose and who were then treated with doses
of 50-150 mCi of 131I (Table 1). Group II (n 8) was comprised
of patients in whom iodine uptake in distant métastases was
not observed after the 131I tracer dose, but who were treated
with doses of 50-150 mCi of 131I (Table 2). Group III (n 5)
was comprised of untreated patients in whom iodine uptake
in distant métastases was not observed after the 131I tracer dose
(as in Group II) (Table 3). Because this was a retrospective
ease
=
=
=
analysis, patients were in either group II and III based on nonrandomized treatment decisions.
1311 total-body scans
131I tracer was administered 2 weeks after total thy¬
roidectomy, when patients developed hypothyroidism (low
FT4 and high thyrotropin [TSH] value). All patients had a
serum TSH concentration of 30 mlU/L or more. All patients
put on an iodine-restricted diet 1 week before admin¬
istration of the 131I tracer dose. We did not measure the uri¬
nary iodine value of the subjects in this study. Nagataki, et
al., reported that the average urinary iodine excretion was
were
Table 2. Patients
No.
Gender
F
F
F
F
F
M
M
M
Age
(yrs)
74
51
45
52
70
59
54
55
His.
ope
Site of
metastasis
at
F
Bone,
Bone,
Tg
(ng/mL)
16.9
351.6
N.E
688.9
38.5
286.0
Lung, Trachea 244.5
1710.0
Bone
Lung
Lung
Lung
Lung
Bone, Lung
Lung
of
Group II
Dose"
131I
(mCi)
uptake
52
150
126
150
150
50
150
50
Outcome
D(4)b
D(5)
D(3)
D(2)
D(2)
D(2)
D(3)
D(2)
p53 gene Anaplastic
mutation
changes
NE
+
+
NE
+
+
+
Cause of
death
RF
RF
RF
RF
RF
RF
RF
RF
His. at
Autopsy
F
Ana
Ana
Ana
Ana
His., histologie diagnosis; Tg, thyroglobuline at administration of 131I tracer dose; P, papillary carcinoma; F, follicular carcinoma; (-), no
accumulation of 131I outside thyroid bed by posttherapy scans in 131uptake; D, deceased; NE, not examined; RF, respiratory failure; HF, heart
failure; Ana, Anaplastic carcinoma.
aTherapeutic dose.
bNumbers between parentheses represent the survival period (years) after thyroidectomy.
977
131l THERAPY FOR PATIENTS WITH METASTASES FROM THYROID CANCERS
Table 3. Patients
Patient
No.
Gender
Age
(yrs)
M
F
F
F
F
68
55
51
48
68
His.
at
Site of
metastasis
ope
NE
251.0
93.0
NE
261.0
Mediastinal LN
Lung
Lung, Adrenal
Mediastinal LN
Group III
Outcome
Tg
Bone, Lung, Heart
F
P
P
F
P
of
D
D
D
D
D
p53 gene
mutation
Anaplastic
changes
(0)b
Cause of
death
DIC
RF
RF
RF
RF
(3)
(10)
(0)
(8)
His. at
Autopsy
F
P
Ana
F
His., histologie diagnosis; Tg, thyroglobuline at administration of 131I tracer dose; P, papillary carcinoma; F, follicular carcinoma; LN,
lymph node; D, deceased; RF, respiratory failure; Ana, Anaplastic carcinoma; DIC, disseminated intravascular coagulation
aNumbers between parentheses represent the survival period (years) after thyroidectomy.
less than 200
ese
¿ig/day on the iodine-restricted diet in Japan¬
patients (11). An 131I total-body scan was performed both
24 hours after administration of 131I tracer dose for each pa¬
tients, and 5-7 days after therapeutic 131I doses of 50-150
mCi for patients of group I and group II, using a large view¬
ing field -camera.
Radiation
therapy
therapy was performed 2 weeks after the 131I tracer
dose was administered. Therapeutic doses were adminis¬
tered to patients in whom iodine uptake was evident out¬
side the thyroid bed (group I) and to patients in group II
who showed no evidence of iodine uptake outside the thy¬
roid bed. The remaining patients with no extrathyroid iodine
uptake did not receive 131I therapy (group III).
131I
p53 Immunohistochemistry
Thyroid carcinoma tissues were obtained from each patient
15, group II,
6; group
during thyroidectomy (group I,
III,
5). All samples showed differentiated thyroid carci¬
nomas (papillary carcinoma,
17; follicular carcinoma,
9). Paraffin sections were prepared and after deparaffinization, each specimen was boiled four times, 5 minutes each, in
phosphate buffered saline in a microwave oven, and then
=
=
=
=
=
fixed in 0.3% H202 with distilled deionized water (DDW) to
block endogenous peroxidase activity. The sections were
stained with anti-p53 antibody (MAb D07 Dako, Glostrup,
Denmark) diluted 1:100 for 1 hour at room temperature, us¬
ing the streptavidin horseradish peroxidase technique.
Results
Tables 1-3 show the results of investigations in all 32 pa¬
tients. Seventeen patients died within 10 years of surgery.
Table 4. Summary
Type
Group
I
II
6
III
5
F
F
Total
p53
15
F
26
of
7
6
0
3
2
26
Patients (group I) in whom métastases showed accumula¬
tion of 131I after both the tracer dose and therapeutic dose of
131I, exhibited a higher survival rate than patients in whom
métastases did not show accumulation of 131I (groups II and
III). Patients in group I, who were alive, did not have any
clinical symptoms and signs suggesting anaplastic changes,
such as rapid tumor growth, high fever, and pain during ob¬
servation. In our study, all patients in group II died within
5 years of surgery and four of the eight exhibited anaplastic
changes in the métastases. However, in group III, two pa¬
tients survived longer than 5 years (8 and 10 years), one of
whom exhibited anaplastic changes in the métastases after
10 years. The principal causes of death related to thyroid car¬
cinoma were respiratory failure caused by infection or pul¬
monary bleeding (i.e., disseminated intravascular coagula¬
tion) or trachéal obstruction by the large mass of metastatic
carcinoma. Anaplastic changes were observed in 5 of 17 de¬
ceased patients during autopsy (Tables 2 and 3).
Eleven of twenty-six (42.3%) excised thyroid tissue sam¬
ples showed strong (mutant) p53 expression via immuno¬
histochemistry (Table 4). Comparison of cancer type showed
mutant p53 expression in 7 of 17 (41.2%) papillary carcino¬
mas and 4 of 10 (40.0%) follicular carcinomas. Seven of the
fifteen patients examined (46.7%) in group I exhibited mu¬
tant p53 expression, of whom three patients with papillary
carcinomas survived, but two of four patients with follicu¬
lar carcinomas died, one from respiratory failure after 4 years
and the other from heart failure after 9 years. Three of six
(50.0%) patients (all with papillary carcinoma) in group II
exhibited mutant p53 expression. Furthermore, all three
of these mutant p53-positive tumors exhibited anaplastic
changes within 5 years of 131I therapy. Figure 1A shows his¬
tologie sections of one such patient with papillary configu¬
rations present in the primary tumor (Table 2, Patient No. 3)
during total thyroidectomy. Consecutive sections from the
p53 Immunohistochemistry
mutation (%)
3
4
3
0
1
0
(37.5)
(57.1)
(50.0)
(0.0)
(33.3)
(0.0)
11
Alive
Deceased
Anaplastic
changes
o
2
3
0
1
0
0
0
3
0
1
Ü
6
4
978
SERA ET AL.
'
'S
II
s
t
*
specimen shown in Figure
,
4
,
1A exhibited
strong p53 expres¬
immunohistochemistry (Figure IB). This tumor un¬
derwent anaplastic changes after 3 years (Figure 1C). In con¬
-
sion via
4#
¿,,6
trast, all
p53-negative patients
in group II died within the
study period without undergoing anaplastic changes. In
group III, only one of five tumors (20%) exhibited mutant
p53 expression. This tumor exhibited anaplastic change and
the patient died from thyroid carcinoma related complica¬
tions 10 years after 131I tracer scintigraphy.
Discussion
*
B
C rv,y>
mmamm
,
FIG. 1. A. Microscopy of differentiated papillary carcinoma
in a section during total thyroidectomy. B. Positive p53 immunostaining in consecutive sections from the differentiated
papillary carcinoma shown in A. C. Microscopy of anaplas¬
tic carcinoma from a section at autopsy from the same pa¬
tient (see Table 2: Patient #3). Anaplastic changes developed
after 131I therapy. Magnification X 400.
The results showed that patients with tumors that accu¬
mulated 131I did better than patients whose tumors that did
not. A significant benefit from 131I therapy was observed in
patients with remote métastases that showed accumulation
of 131I after both the tracer and therapeutic doses, but not in
patients with remote métastases that failed to show such ac¬
cumulation.
In our study, all patients in group II died within 5 years
of surgery, and four of the eight exhibited anaplastic changes
in the métastases. However, in group III, two patients sur¬
vived longer than 5 years (8 and 10 years), one of whom ex¬
hibited anaplastic changes in the métastases after 10 years.
However, statistically, there was no significant difference be¬
tween groups II and III with Kaplan-Meier analysis (Data
not shown). Crile, et al. (12) and Leeper (6) reported two
cases of rapidly fatal anaplastic carcinoma in patients with
papillary-thyroid cancer treated with 131I. However, it has
been reported that 131I therapy does not cause anaplastic
transformation (13). Our results suggest that insufficient 131I
therapy may, in fact, trigger early anaplastic changes. Be¬
cause this study was a retrospective analysis, there is a pos¬
sible bias for our results.
The p53 tumor-suppressor gene has been implicated in tu¬
mor progression in the thyroid gland. Several studies have
shown that both p53 overexpression and p53 gene mutations
are far more frequent in poorly differentiated and anaplas¬
tic carcinomas than in well-differentiated papillary and fol¬
licular carcinomas (15-17). In order to evaluate the relation¬
ship between early anaplastic change after insufficient 131I
therapy and p53 mutation in primary thyroid-carcinoma tis¬
sues, we examined p53 gene mutations via immunohisto¬
chemistry in 26 thyroid carcinomas obtained via total thy¬
roidectomy. Wild-type p53 protein has a short half-life, but
mutation of the p53 gene confers a longer half-life on the mu¬
tant protein (18,19) thereby leading to its accumulation.
Positive p53 expression therefore represents mutated p53
(18,20). Eleven of twenty-six tumors analyzed in our study
exhibited p53 gene mutations. Further analysis of our results
showed that neither tumor histology (papillary or follicular
carcinoma) nor 131I uptake correlated with p53 gene muta¬
tion.
Recent reports have
suggested that p53 plays a role in thy¬
roid tumor progression via cell dedifferentiation and/or en¬
hanced biologic aggressiveness (21), and the presence of p53
gene mutations confers a poor prognosis (22). Our results,
however, demonstrated no relationship between p53 gene
mutation and prognosis in patients who underwent suc¬
cessful 131I therapy. Furthermore, three differentiated thy¬
roid carcinomas with p53 gene mutations, which were
treated with 131I therapy but exhibited no 131I uptake, all de-
979
THERAPY FOR PATIENTS WITH METASTASES FROM THYROID CANCERS
veloped anaplastic changes within 5 years of therapy. One
patient with a p53 gene mutation, who did not receive
131I therapy because of poor 131I accumulation, developed
anaplastic changes, but not until 10 years after the 131I tracer
dose. 131I therapy has not previously been reported as a pos¬
sible trigger for anaplastic changes but our results suggest
this possibility. After therapeutic neck irradiation, Fogelfeld,
et al. (23) reported an increased frequency of p53 gene mu¬
tation in thyroid carcinomas. In this regard, Namba and
coworkers (24) postulated that the p53-WAFl/Cipl pathway
play a role in induction of Gl arrest in human thyroid ep¬
ithelial cells following irradiation. The absence of Gl arrest
following low-dose irradiation suggests a failure of the deoxyribonucleic acid repair process. Furthermore, the lack of
131I concentrating activity already implies some loss of dif¬
ferentiation. We postulate that this process results in pro¬
gressive dedifferentiation of the carcinoma cells until, finally,
producing anaplastic changes.
In conclusion, 131I therapy may be useful for patients with
distant métastases from thyroid cancer, with or without p53
gene mutations, when such tumors show accumulation of
131I after tracer doses. Conversely, 131I therapy is ineffective
in patients who do not show an accumulation of 131I, and in
such patients, p53 gene mutation may trigger early anaplas¬
tic
changes.
12.
13.
14.
15.
16.
17.
18.
19.
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Address
reprint requests to:
Katsumi Eguchi
First Department of Internal Medicine
Nagasaki University School of Medicine
Prof.
1-7-1 SaL·moto
Nagasaki 852-8501
Japan
E-mail:
Eguchi@net.nagasaki-u.ac.jp