Nghiên cứu đặc điểm lâm sàng, cận lâm sàng, đột biến gen BRAF v600e và kết quả điều trị ngoại khoa ung thư tuyến giáp tt tiếng an

MINISTRY OF EDUCATION AND MINISTRY OF TRAINING
VIETNAM MILITARY MEDICAL ACADEMY

BUI DANG MINH TRI

STUDYING CLINICAL CHARACTERISTICS,
SUBCLINICAL, BRAF V600E GENE MUTATION
AND RESULTS OF SURGICAL TREATMENT
THYROID CANCER

Specialization: Surgery
Code: 9720104

SUMMARY OF THE THESIS OF MEDICINE

HA NOI – 2019


RESEARCH WORKS IS COMPLETED AT:
VIETNAM MILITARY MEDICAL ACADEMY

Science instructor:
1. Assoc. Professor Ph.D Mai Van Vien
2. Assoc. Professor Ph.D Nghiem Duc Thuan

Critic 1: Professor. Ph.D Le Ngoc Thanh
Critic 2: Assoc. Professor Ph.D Le Dinh Roanh
Critic 3: Assoc. Professor Ph.D Nguyen Huu Uoc

The thesis will be protected at the University-level Thesis Assessment
Council Meeting at: Military Medical Academy

on ..... ..... hours ..... day ..... month ..... year 2019

The thesis can be found at:
- Vietnam National Library.
- Library of Military Medical Academy


1
INTRODUCTION TO THE THESIS

QUESTION
According to the Patient Survivor Association of Thyroid Cancer
(2012), thyroid carcinoma is the most common endocrine cancer [1].
Peterson E., De P., and Nuttall R. (2012) stated [2] over the past 30 years,
many countries have recorded a significant increase in the incidence of
thyroid carcinoma, an average increase of 67% in women and 48% in men
between 1973 and 2002. In the United State (US), according to the report
of Morrison S.A. (2014) [3] the number of cases increased by 25% in 3
years, more than 56,000 people were diagnosed with new thyroid cancer
in 2012 and there are more than 200,000 new diagnoses worldwide in a
year. Patient's Association for the Survival of Thyroid Cancer [1] also
thinks that about 70% of people diagnosed with thyroid carcinoma are
aged between 20 and 55 and the male / female ratio = 7/3.
Thyroid carcinoma is divided into two types including
differentiation and non-differentiation. Differentiation is dominant,
including papillae, follicles and papillae. Without differentiation,
including the marrow, it can be indeterminate.
According to Kaczka K., et al. (2012) [7] in most cases, after
surgery to remove the thyroid nucleus, the pathology of the thyroid
gland is diagnosed by histology with conventional HE staining.

However, there are insufficient cases of subclinical information to
distinguish between benign and malignant lesions if only regular HE
staining is used. Many studies of the authors Lange D. (2004) [8],
Demellawy D.E. (2008) [9] and Fischer S. (2008) [10] and their
colleagues have shown that tissue culture is immune to the Antigenic
markers - specific antibodies can help clearly distinguish and diagnose
the thyroid disease.
According to Cooper D.S. (2009) [11], surgical removal of the
thyroid gland is the most effective way to treat papillary thyroid
carcinoma. In addition, the great talent of Stack B.C. (2012) [12], Lee


2
B.J. (2007) [13], Keum H.S. (2012) [14] and colleagues also claimed
that the dredging to the neck lymph nodes was Groups IIa, III, IV and
Vb are recommended when indicated to optimize treatment efficacy.
The American Thyroid Association (2010) [15] and the British
Thyroid Association [16] believe that thyroid carcinoma has a good
prognosis if diagnosed early, treated properly and promptly. However,
up to 7-10% of papillary thyroid cancer patients die within 10 years of
being diagnosed.
The author Lathief S. (2016) [17] suggested that although most
thyroid carcinoma can be determined before surgery by cytology, there
are about 20 - 30% of cases. cannot be determined by routine tests.
Many studies of authors such as Cheung C.C. (2001) [18], Lange D
(2004) [8], Nechifor-Boilă A. (2014) [19], Demellawy D.E. (2008) [9]
and Wielganowicz M.J. (2003) [20] have shown that
immunohistochemistry with specific antigen-antibody markers can help
to better distinguish the pathological status of the thyroid gland. In
recent years, Liu C. (2016) [21] and Liu X. (2014) [22] have

documented the role of BRAF V600E gene mutation in cancer
diagnosis and prognosis. papillary thyroid epithelium.
1. Research objectives
These issues have not been systematically studied in Vietnam.
From the above fact, we carried out the thesis: "Research on clinical,
subclinical characteristics, mutations of BRAF V600E gene and results
of surgical treatment of thyroid cancer" with the following objectives:
- Analysis of some clinical, subclinical, histopathological,
immunohistochemistry, BRAF V600E mutations in patients with
differentiated thyroid cancer.
- Identify some relevant factors and evaluate the results of
surgical treatment of differentiated thyroid cancer.
2. New contributions of the thesis
From the study results, 102 patients with thyroid carcinoma


3
were treated with surgery from 7/2013 to 6/2018 at Military Hospital
103, we found new contributions as follows:
2.1. Comments on clinical, subclinical, histopathological, immunohistochemistry,
BRAF gene mutation V600E in differentiated thyroid carcinoma patients
- We find that the majority of women with thyroid carcinoma can
be differentiated and 4.67 times more than men, besides most patients
hospitalized due to abnormal mass in the neck area. before (accounted
for 86.3%).
- Patients with metastatic lymph nodes are 100% dredged.
- 84.3% of patients with thyroid carcinoma differentiated at T2
level, 11.8% had metastatic lymph nodes before surgery.
- 52.0% of thyroid carcinoma in stage I; 48% in Phase II - III.
- 99% of patients were positive for HBME-1, 100% were positive

for CK19, 62.7% were positive for COX-2, 52.9% were positive for
p53, 32.4% were positive for Ki67 and 89.2% positive for RET.
- 60.8% of patients with thyroid carcinoma have BRAF mutation
at position T1799A (V600E). The rate of BRAF mutation was higher in
the COX-2 positive group compared to the negative group (p <0.05).
The rate of BRAF mutation was higher in the group with Ki67 negative
compared to the positive group (p <0.05).
- There was no association between BRAF mutation,
immunological markers of tumor characteristics, lymph node metastasis
and Thyroglobulin concentration.
2.2 Identify some relevant factors and evaluate the results of surgical
treatment of differentiated thyroid carcinoma at Military Medical
Hospital 103
- Without complications, or complications occur, tetani bout
after surgery and bleeding after surgery account for a low rate of 1%.
- Monitoring results after 1 month:
+ There are no patients with severe neurological damage,
hypoparathyroidism.


4
+ Concentrations of FT3, FT4, Tg after surgery reduced and
increased TSH levels indicated that the treatment was effective.
- Follow up relapse: cumulative recurrence rate 11.78%.
- When univariate analysis of prediction of BRAF V600E gene
mutations and gender with risk of recurrence after surgical treatment
and I-131 treatment, we found out among study patients:
+ Patients with BRAF V600E gene mutation have a higher
recurrence rate.
+ Female patients have a higher recurrence rate than male

patients.
- When univariate analysis of prediction of BRAF V600E gene
mutations and gender with recurrence time after surgical treatment and
I-131 treatment, we found out among study patients:
+ The average time of metastasis appears in the group of
patients with the BRAF V600E mutation earlier.
+ The average time of metastasis occurs in the group of male
patients early.
- Cox model analysis showed that patients mutating BRAF
V600E gene would increase the risk of recurrence by 9.14 times (p =
0.04, log-rank test) compared to the group without mutation.
3. The layout of the thesis
The thesis consists of 135 pages, in addition to the issues,
conclusions and recommendations, the thesis consists of 4 parts:
Chapter 1: Documents overview: 37 pages, chapter 2 - Subjects and
research methods: 28 pages, chapters 3 - Research results: 30 pages,
chapter 4- Discussion: 34 pages. The thesis has 40 tables, 01 diagram,
12 pictures, 05 charts. The thesis uses 125 references.


5
CHAPTER 1: DOCUMENT OVERVIEW
1.1 Clinical manifestations
1.1.1. Functional symptoms
According to the American Cancer Society (2014) [24] in the early
stages, functional symptoms are often poor, of little value. The majority of
thyroid cancer patients come for examination because of the appearance of
thyroid tumors. Thyroid tumors may have long since remained unchanged
but grew larger in a short time and harder. Late stage or large, invasive
tumor and often present with swallowing, shortness of breath, hoarseness.

Noncancerous cancers grow fast, large tumors stick to surrounding tissue,
invasive trachea cause choking.
1.1.2. Physical symptoms
- Thyroid tumors: can show one or more tumors in the thyroid
gland with hard characteristics, clear edges, smooth or rough surface,
moving according to swallowing rhythm. In the late stage thyroid
tumors are usually large, hard, fixed, on the surface of the red skin,
ulcers or bleeding.
- Thyroid tumors can be in one lobe, waist or both lobes.
- Lymph nodes: majority of lymph nodes on the same side
(possibly lateral or bilateral lateral lymph nodes), lymphadenopathy,
supraclavicular, under the jaw, under the chin, thorny lymph nodes with
solid, mobile, painless features. Some cases have lymph nodes before
the primary tumor is found. According to the American Cancer Society
[24] in young adults, neck lymph nodes appear to suggest thyroid
cancer even if the thyroid gland is not palpable but actually thyroid
cancer has been around for many years, some diseases The patient goes
to the hospital because of a distant metastasis, which can be detected by
a thyroid cancer.
Clinical findings of thyroid tumors are sometimes difficult,
especially with small tumors deep in the thyroid tissue and shown to be
limited during clinical examination. The neck cancers are an important sign
to help detect thyroid cancer, lymph nodes are concentrated on both sides
of the trachea, the outer margin, the inner and posterior lobe of the


6
muscular dystrophy, epicardial pits, jaw angle. In some cases, we can only
touch the metastatic lymph nodes, but we have not felt the tumor, but
actually there are very small tumors.

1.2 Subclinical characteristics
- X-ray of the neck and chest area
Radiography is used in the early detection of thyroid diseases.
This method is especially valuable for those behind the sternum, when
the physical examination in the posture of maximum neck resting does
not feel the lower extremity of the tumor, chest radiography is indicated
to determine the posterior tumor. Memory is needed.
- Thyroid ultrasound is a very valuable diagnostic method for
diagnosing thyroid morphology in general and is particularly valuable
when distinguishing tumors with cysts, accurately assessing size,
number, and limit.
- I-131 thyroid and systemic radiography
Systemic I-131 scans are often used to detect recurrence and
metastasis, but this test is only valid after surgery to remove the entire
thyroid, by recording with I-131 after surgery. Thyroid from 4 to 6
weeks, when TSH increases > 30 µIU/ml are eligible for testing. To
assess the results of treatment of remaining thyroid tissue destruction
after surgery, it is recommended to record after 6-12 months after the
previous treatment. For differentiated thyroid carcinoma with lung
metastases, this test High value in diagnosis. Full body radiography is
not only worth discovering but also has prognostic value.
- Prick the cells with small needles
Small needle aspiration has reduced unnecessary thyroidectomy
1.3. Histopathological characteristics
1.3.1. Instant biopsy
Is a rapid diagnostic method of histopathology in surgery to
diagnose thyroid cancer, is applied according to the cold cutting
method. Rapid diagnostic measures for histopathological lesions during
surgery, help surgeons decide appropriate surgical methods, avoid
unnecessary surgery for 20% of patients identified as cancer cells,

Avoid re-surgery because repeated surgery is easy to cause parathyroid
gland damage and laryngeal nerve. According to Jozaghi Y. (2013)


7
[45], instant biopsy has an accuracy of 80-85%.
1.3.2. Diagnosis of histopathology
- Papillary thyroid carcinoma
- Follicular thyroid carcinoma (oncocyte cell carcinoma,
Hurthle cell)
- Thyroid carcinoma can be differentiated
- Thyroid carcinoma is not different
- Squamous cell thyroid carcinoma
- Mucous epidermal thyroid carcinoma
- Mucous epidermal thyroid carcinoma hardened with
eosinophilia
- Mucous thyroid carcinoma
- Medullary thyroid carcinoma
- Rhombic cell cancer with thymus glandular differentiation
(SETTLE)
- Mixed thyroid carcinoma of marrow and follicular cells
- Thymus glandular thyroid carcinoma (CASTLE)
1.4. Characterization of immune tissue
In most cases, diagnosis can be easily based on histological and
clinical evidence. However, in the diagnosis process sometimes
encounter some difficulties:
- Limited tumors with minimal penetration of fibrous skin.
- The lesions suspected of metastasizing from elsewhere.
- Follicular variants and oncocytic cell variants of papillary
thyroid carcinoma, medullary thyroid carcinoma.

One or more combinations of antibodies have significantly
improved the accuracy of the diagnosis of thyroid carcinoma.
Some immunological markers used in the diagnosis of thyroid
carcinoma: RET, HBME - 1, COX - 2, P53, Ki67.
1.5 BRAF V600E gene mutation:
According to the Kurtulmus N. study (2016) [58] the gene
mutation BRAFT1799A is a very valuable molecular marker in the
diagnosis and monitoring of prognosis of thyroid carcinoma. T1799A
mutations only appear in thyroid carcinoma cells that are not found in
benign thyroid cells and identify the BRAF T1799A mutation that will


8
help limit the diagnosis of carcinoma. The thyroid gland is omitted,
improving the quality of medical examination and treatment, and
monitoring and managing patients.
1.7 Treatment of thyroid carcinoma
1.7.1 Surgical treatment
In general, the entire thyroidectomy has the following main
advantages:
+ Higher survival rate and reduced recurrence rate in patients
with thyroid cancer especially in patients with tumor diameter> 1.5 cm,
reducing recurrence rate in opposite thyroid.
+ Facilitating the use of I-131 to treat the destruction of residual
thyroid tissue, detecting relapse and treating regional lymph node
metastasis and distant metastasis.
+ Improve the sensitivity of Tg as a marker for survival and
recurrence, metastasis of differentiated thyroid cancer.
- Surgical methods: Currently, there are many different views
on surgical methods based on the following factors: histopathology,

location, size, quantity, invasive extent of the tumor to the pulse
organization. around, metastatic lymph node metastasis, distant
metastasis ... That cut a lobe or cut the entire thyroid gland, dredge neck
lymph nodes.
1.7.2 Adjuvant treatment after surgery
- Treatment with radioactive isotope I-131
Determination of therapeutic dose: The dose I - 131 for the
treatment of thyroid tissue destruction after surgery, the therapeutic
dose should be adjusted for children and the elderly, poor body.
isolation institute.
- Chemical treatment: According to the American Cancer
Society (2014) [24] chemicals are rarely used to treat thyroid
carcinoma, especially differentiated thyroid carcinoma.


9
CHAPTER 2:
SUBJECTS AND METHODS OF RESEARCH
2.1. Research subjects
Patients were selected for convenient sample sizes, whole and
intentional sampling.
Patients undergoing surgery and diagnosis determined by
histopathological examination are thyroid carcinoma at Military
Medical Hospital 103 from July 2013 to December 2016,
complementary treatment with I- 131 from August 2013 to June 2018 at
Military Medical Hospital 103
+ Criteria for selecting objects of reference group:
- Regardless of age and gender.
- The results of histopathological examination after surgery are
differentiated thyroid carcinoma.

- Differentiated thyroid cancer, progressing in place, without
distant metastasis.
- No distant metastasis. There is no coordinated severe chronic
disease.
- No other cancer combined.
- Have enough medical records to store, record details of
information to help the research in the form.
+ Criteria to exclude patients
- Secondary thyroid cancer due to metastasis from other places.
- Extensive invasive thyroid cancer whose surgery does not
completely cut the entire thyroid.
- Patients do not agree to participate in the study
+ Research method
Description of series, clinical interventions, cross-sectional
descriptions, vertical monitoring, non-control. Complete and intentional


10
sampling. All patients were carefully studied about history, medical
history, clinical examination, doing laboratory tests according to a
unified study medical record which was approved by the Scientific
Council of the Military Medical Academy. by.
2.2. Implementation process
2.2.1. Determination of hormone FT3, FT4, TSH, thyroglobulin (Tg)
and anti-thyroglobulin (anti - Tg)
Proceeding before and after surgery at the Department of
Biochemistry - 103 Military Hospital:
- Supersonic
It is implemented in Functional Diagnosis Department Military Medical Hospital 103.
Use a conventional ultrasound machine with an appropriate

probe to probe the thyroid gland.
- Aspirate thyroid tumor cells and neck lymph nodes with small
needles under the guidance of preoperative ultrasound
Conducted in the Department of Disease Surgery - Military
Medical Hospital 103
According to the technical process of the Ministry of Health
(2013) [10]
2.3. Processing and analyzing data
According to the medical statistical method, use SPSS 22.0
software. Evaluate:
p>0.05: the difference is not statistically significant
p<0.05: the difference is statistically significant
2.5. Ethical issues in research
- Research subjects are voluntary.


11

Patients
suspected of
thyroid
cancer
Clinical Thyroid hormoneinter sound

Thyroid tumor
Perform FNA under the
guidance of ultrasound

Surgery indicatiom

Instant biopsy

Surgery

Path.Anatopy
Im-chem.tests
BRAF gene test

Evaluation

I-131 treatment

TNM stage

Conclusion

Diagram 2.1. Research diagram


12
CHAPTER 3:
RESEARCH RESULTS
3.1. General characteristics of research subjects
- Gender characteristics
Mostly female patients (82.4%); female / male ratio = 4.67 / 1.
- Age characteristics: The average age is 45.14 ± 13.42 years old
- In our study, 100% of patients showed thyroid tumors; The
number of cases with swallowing problems also accounted for a high
rate of 37.3%. Other clinical manifestations with less prevalence such as
dyspnea 12.7%, 8.8% hoarseness.

- Among patients with neck lymph nodes, group V accounts for
33.3%, mainly 1 lymph node accounts for 66.7% and size ≥ 2 cm accounts
for 50%. The average size of lymph nodes is 1.73 ± 0.85 cm.
- Based on the TNM classification table (2014) of the American
Cancer Society. In our study 84.3% of patients with differentiated
thyroid carcinoma at T2 level, there were 2 cases accounting for 2.0% at
T3 level; 13.7% at T1 level; 11.8% of patients with thyroid carcinoma
have metastatic lymph nodes. There are no cases of distant metastasis.
- Most patients have thyroid hormone tests within normal
limits. However, up to 15.6% of patients increased FT3. These are
patients with thyroid carcinoma based on background or patients who
are using synthetic anti-thyroid drugs.
- 100% of patients with histopathological results are papillary
thyroid carcinoma. 61.76% of patients were given immediate biopsies
and 100% of patients were given TG suction with small needles to
make a diagnosis. Comparison of results of small needle aspiration at
preoperative thyroid tumors with histopathological results after surgery
showed a positive rate of 64.7% and a false negative rate of 35.3%.


13
3.2. hospitalization reason
Table 3.1. Hospitalization reasons
Hospitalization reason
Quantity
Rate (%)
Unusual mass in the neck area first
88
86.3
Swallowing problems

4
3.9
Shortness of breath
5
4.9
Other reasons
5
4.9
Total
102
100
The majority of patients were admitted to hospital with the reason that
the abnormal neck area was 86.3%.
Table 3.2. Relationship between BRAFV600E gene mutation and
immunological imprint
BRAF V600E gene
No
Yes
mutation
(n=40)
(n=62)
OR
p
Immune
Quanti
Quanti
Rate%
Rate%
imprint
ty

ty
≤ 3+
29
72.5
33
53.2
2.32 0.052
4+
11
27.5
29
46.8
1+ và 2+
9
22.5
12
19.4
CK19
1.21 0.701
3+ và 4+
31
77.5
50
80.6
Negative
21
52.5
17
27.4
COX-2

2.93 0.011
Positive
19
47.5
45
72.6
Negative
22
55.0
26
41.9
p53
1.69 0.197
Positive
18
45.0
36
58.1
Negative
33
82.5
36
58.1
Ki67
3.41 0.010
Positive
7
17.5
26
41.9

Negative
6
15.0
5
8.1
RET
2.01 0.270
Positive
34
85.0
57
91.9
- 72.6% of BRAFV600E mutants had COX-2 positive markers,
while the COX-2 positive rate in the non-mutant group was 47.5%. The
difference was significant (p = 0.01). The risk of a BRAFV600E
mutation in a positive COX-2 patient group was 2.93 times the negative
group.
HBME-1


14
- 41.9% of BRAF V600E mutant patients had a positive Ki67
marker, while positive Ki67 rate in the non-mutant group was 17.5%.
The difference is significant (p = 0.01). The risk of mutation of BRAF
V600 gene in Ki67 patients group is 3.41 times higher than the negative
group.
3.3 Surgical follow-up results after 1 month
Table 3.3. Association between recurrence rate with some clinical
features before treatment
Relapse

No
Yes
Clinical

(n=90)

(n=12)

P

n
%
n
%
T1
13
14.4
1
8.3
T
T2
75
83.3
11
91.7
0.73
T3
2
2.3
0

0
N0
81
90
9
75
N
0.15*
N1
9
10
3
25
I
48
53.3
5
41.7
Phase
II
40
44.4
5
41.7
0.05
III
2
2.3
2
16.6

Female
77
85.6
7
58.3
Sex
0.02
Male
13
14.4
5
41.7
< 45
46
51.1
5
41.7
Age
0.54
≥ 45
44
48.9
7
58.3
Yes
51
56.7
11
91.7
BRAF V600E

0.02*
gene mutation
No
39
43.3
1
8.3
- Patients with BRAF V600E gene mutation had a higher recurrence
rate (91.7% compared to 8.3%) without mutation (p = 0.02).
- Female patients have a higher recurrence rate than male patients,
the difference is statistically significant (p = 0.02).


15
Bảng 3.4. Comparison of thyroid hormone levels before and after
surgery 1 month
1 month after
Hormone testing
Before surgery
surgery
N
102
102
FT3
3.22 ± 0.78
2.96 ± 0.66
± SD
(nmol/l)
p*
0.016

N
102
102
FT4
0.96 ± 0.19
0.66 ± 0.24
± SD
(ng/dl)
p*
< 0.001
N
102
102
TSH
1.86 ± 3.06
24.51 ± 30.93
± SD
(µIU/ml)
p*
< 0.001
N
102
102
Tg
78.04 ± 125.29
36.29 ± 93.76
± SD
(ng/ml)
p*
< 0.001

N
102
102
Anti-Tg
92.27
±
425.56
58.93
± 241.93
± SD
*
(ng/ml)
p
0.11
Concentrations of FT3, FT4, Tg after surgery decreased and TSH
levels increased significantly compared to before treatment (p <0.05).
At the end of recording information (June 30, 2018), we
recorded that 12/102 cases of relapse accounted for 11.67% and there
were no deaths.
Table 3.5. The number of patients recorded relapsed according to the
follow-up time
Number of
Number of reTimes
Rate %
patients relapse examination patients
6 months
0
102
0,0
12 months

6
102
5.88
18 months
3
102
2.94
24 months
2
62
1.96
36 months
1
28
1.0
48 months
0
16
0


16
60 months
0
6
0
Total
12
102
11.78

There were 12/102 patients recorded and monitored
postoperative relapses (clinical examination, ultrasound appearance of
thyroid tissue, the appearance of neck lymph nodes was diagnosed with
small needle aspiration, functional measurement. Thyroid, measurement
of > 10 ng/ml of Thyroglobulimine, thyroid radiography, systemic scan
with positive results) in which the 12-month period was most recorded.
Group of relapsed patients treated with relapse with radioactive
substances I-131: metastatic lymph nodes: 150 mCi, lung metastasis:
100-150 mCi, distant metastases (bone, brain ...): 200- 250 mCi.
Table 3.6. Relation between recurrence rate and some pre-treatment
clinical characteristics
Relapse
No
Yes
(n=90)
(n=12)
P
Clinical
N
%
n
%
T1
13
14.4
1
8.3
T2
75
83.3

11
91.7
T
0.73
T3
2
2.3
0
0
N0
81
90
9
75
N
0.15*
N1
9
10
3
25
I
48
53.3
5
41.7
Phase
II
40
44.4

5
41.7
0.05
III
2
2.3
2
16.6
Female
77
85.6
7
58.3
Sex
0.02
Male
13
14.4
5
41.7
< 45
46
51.1
5
41.7
Age
0.54
≥ 45
44
48.9

7
58.3
Yes
51
56.7
11
91.7
BRAF V600E
0.02*
gene mutation
No
39
43.3
1
8.3
* Fisher’s 2-side inspection
- Patients with BRAF V600E gene mutation had a higher
recurrence rate (91.7% compared with 8.3%) without mutation (p = 0.02).


17
- Female patients have a higher recurrence rate than male
patients, the difference is statistically significant (p = 0.02).
Table 3.7. Relationship between immune imprints and relapses
Relapse
No
Yes
(n=90)
(n=12)
OR

p
Immune
Tỷ lệ
Tỷ
SL
SL
Imprint
%
lệ%
+
≤3
56
62.2
6
50
HBME-1
1.65 0.42
+
4
34
37.8
6
50
1+ và 2+
19
21.1
2
16.7
CK19
1.34 1.0*

3+ và 4+
71
78.9 10
83.3
Negative
33
36.7
5
41.7
COX-2
0.81 0.74
Positive
57
63.3
7
58.3
Negative
43
47.8
5
41.7
p53
1.28 0.69
Positive
47
52.2
7
58.3
Negative
61

67.8
8
66.7
Ki67
1.05 1.0*
Positive
29
32.2
4
33.3
Negative
10
11.1
1
8.3
RET
1.38 1.0*
Positive
80
88.9 11
91.7
- Patients with BRAF V600E gene mutation had a higher
recurrence rate (91.7% compared to 8.3%) without mutation (p = 0.02).
- Female patients have a higher recurrence rate than male
patients, the difference is statistically significant (p = 0.02).
Table 3.7. Relationship between immune imprints and relapses
* Fisher’s 2-side inspection
No association has been found with immunological imprints.
Table 3.8. Time of recurrence with some related characteristics
Average time (months)

p*
Characteristics
31.81 ± 1.14
Yes
BRAF V600E
0.01
gene mutation
No
57.82 ± 2.08
39.45 ± 7.24
Male
Female
55.59 ± 1.6
* Testing of Independent-Samples T Test
Sex

0.02


18
- The relapse time in patients with BRAF V600Es mutation was earlier
than in patients without mutations (p = 0.01).
- The relapse time in male patients is earlier than in female patients
(p=0.02).

Figure 3.1. The risk of recurrence in patients with BRAFV600E
mutation
Kaplan-Meier chart showed that the group of patients with
BRAF V600E gene mutation increased the risk of recurrence compared
to the group without mutations 9.14 times, statistically significant (p =

0.04) (Log test -rank).


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CHAPTER 4: DISCUSSION
4.1. Clinical characteristics, subclinical thyroid carcinoma
4.1.1. Age and gender
In our study, mainly patients aged 40 - 49 accounted for 25.4%;
30-39 and 50 - 59 together account for 21.6%. The lowest age in study
17; The highest age is 80. The average age is 45.14 ± 13.42. Mostly
female patients (82.4%); female / male ratio = 4.67/1.
4.1.2. Clinical symptoms
In our study, 100% of patients showed thyroid tumors; The
number of cases with swallowing problems also accounted for a high
rate of 37.3%. Other clinical manifestations with less prevalence such as
dyspnea 12.7%, 8.8% hoarseness.
Our study found that among patients with neck lymph nodes,
group V accounted for 33.3%, mainly 1 lymph node accounted for
66.7% and size ≥ 2 cm accounted for 50%. The average size of lymph
nodes is 1.73 ± 0.85 cm.
4.1.3. TNM classification and disease diagnosis
Upon further investigation, we found no association between
tumor invasion, neck lymph node metastasis and some clinical features
from the time of disease detection to surgery (p> 0.05).
There was no significant difference between the rate of lymph node
metastasis and tumor and gender invasion (p> 0.05). This result is
similar to that of Liu C. (2016) [21]. The average age of patients with
no lymph node metastasis was 45.60 ± 13.51 and for patients with
metastatic lymph nodes was 41.67 ± 12.66.
4.1.4. Results after surgery

In our study, 60.8% of patients with thyroid carcinoma had
BRAF mutation at position T1799A (V600E).
But when comparing the rate of BRAF mutation with cases of
revealing immunohistochemistry, we found:
- 72.6% of BRAFV600E mutants had COX-2 positive markers,
while the COX-2 positive rate in the non-mutant group was 47.5%. The
difference was significant (p = 0.01). The risk of a BRAFV600E


20
mutation in a positive COX-2 patient group was 2.93 times the negative
group.
- 41.9% of BRAF V600E mutant patients had a positive Ki67
marker, while positive Ki67 rate in the non-mutant group was 17.5%.
The difference is significant (p = 0.01). The risk of mutation of BRAF
V600 gene in Ki67 patients’ group is 3.41 times higher than the
negative group.
4.2. Results after surgery from 1 to 36 months
With a small number of patients re-examined, not much has
been assessed, especially the issue of prognosis and extra lifetime. As a
first step, we found:
The incidence of neck lymph nodes of patients after 1 month is
16.7%.
Concentrations of FT3, FT4, Tg after surgery decreased and
TSH levels increased significantly compared to before treatment (p
<0.05).
4.3. Identify some related factors
At the end of recording information (June 30, 2018), we
recorded that 12/102 cases of relapse accounted for 11.67% and there
were no deaths. Among patients with metastatic lymph node metastasis,

group V accounted for 33.3% (number of 2 lymph nodes), mainly 1
lymph node accounted for 66.7% and size ≥ 2 cm accounted for 50.0%.
Randolph G.W. (2012) [70] showed a difference in recurrence
rates in lymph node sites. The relapse rate of patients in the N0 stage
when hospitalized was 2% (about 0% -9%) lower than the cases in the
N1 stage when hospitalized was 22% (about 10% -42%). In addition, the
average risk of relapse in patients in stage N1 changes markedly by
number of lymph nodes, <5 lymph nodes (4%, about 3% -8%)
compared with> 5 lymph nodes (19%, about 7 % -21%).
When univariate analysis of prediction of BRAF V600E gene
mutations and gender with risk of recurrence after surgical treatment
and I-131 treatment, we found:


21
Among the study patients, patients with BRAF mutation V600E
had a higher recurrence rate (91.7% compared to 8.3%) without
mutation (p = 0.02).
Among the study patients, female patients had a higher recurrence rate
than male patients, the difference was statistically significant (p = 0.02).
When univariate analysis of prediction of BRAF V600E gene
mutations and gender with relapse after surgical treatment and I-131
treatment, we found:
- Among the studied patients, the average time of metastasis
appeared in the group of patients with BRAF V600E gene mutation
earlier than the group without the mutation (p = 0.01) was 31.81 ±
1.00, 14 months with 57.82 ± 2.08 months. The difference is significant
with the Independent-Samples T test.
- Among the studied patients, the average time of metastasis in the
male patient group was earlier than the female patient group (p = 0.02) was

39.45 ± 7.24 months compared to 55.59 ± 1.60 months. The difference is
significant with the Independent-Samples T test.
Cox model analysis showed that patients with BRAF V600E
mutation would increase the risk of recurrence by 9.14 times (p = 0.04,
log-rank test) compared to the group without the mutation.
Some Korean researchers like Hwangbo Y. (2017) [121]
multicenter retrospective study 3,282 thyroid carcinoma patients with
size ≤ 2cm treated with surgery in Korea. The author used KaplanMeier Analysis and Cox regression model to analyze recurrence and
risk factors. The results showed that preoperative lymph node
metastasis, tumor lumpectomy, tumor size ≥1.8 cm, and multifocal
tumors were independent risk factors for relapse.
The first study of Wada N. (2007) [117] studied 134 patients
with thyroid carcinoma (42 patients with positive lymph nodes and 92
patients without lymph nodes) who underwent complete thyroidectomy.
be monitored rate of recurrence by Kaplan-Meier method and log-rank
test. The results showed that the recurrence rate in the group with


22
positive lymph nodes was 15.8% higher than in the group without 2.7%
lymph nodes (p <0.001).
Recent research by Mansour J. (2018) [122] summarizes 9
retrospective studies, including 12,000 thyroidectomy and lymph node
surgeries in patients with thyroid carcinoma, the results of the analysis
show that there is a link between them. stage N1 with the risk of
recurrence and mortality in patients with thyroid carcinoma.
Similarly, Tam S. 's study (2018) [105] surveyed 2579
differentiated thyroid cancer patients who underwent surgery from 2000
- 2015. The author used Kaplan-Meier analysis and Log- test. Rank
shows the factors associated with the patient's survival rate are age > 55,

tumor size and distant metastasis.
In our study, there was no correlation between neck movement
and recurrence rate after surgical treatment and I-131 treatment,
different from the results of other studies in the world.
Researchers Liu C. (2016) [21] analyzed 34 studies with 20,764
patients, the authors found that the BRAF gene mutation is associated
with a number of clinical characteristics such as disease stage and
lymph nodes before surgery as well as the risk of relapse, but there is no
relation to distant metastasis.
In our study, we have not found an association between gene
mutations, immunohistochemistry with some other clinical and
subclinical characteristics. Perhaps due to the short follow-up time, the
number of patients with less follow-up should not fully evaluate the
predicted role, prognosis of immune markers as well as BRAF V600E
gene mutations in thyroid carcinoma.


23

CONCLUSION
From the study results, 102 patients with thyroid carcinoma
were treated with surgery from 7/2013 to June 2018 at Military Hospital
103, we draw some conclusions as follows:
1. We found that the majority of women with thyroid carcinoma can be
differentiated and 4.67 times more than men, besides the majority of
patients hospitalized due to abnormal mass in the neck area (86.3%).
- 84.3% of patients with thyroid carcinoma differentiated at T2
level, 11.8% had metastatic lymph nodes before surgery.
- 99% of patients were positive for HBME-1, 100% were positive
for CK19, 62.7% were positive for COX-2, 52.9% were positive for p53,

32.4% were positive for Ki67 and 89.2% positive for RET.
- 60.8% of patients with thyroid carcinoma have BRAF
mutation at position T1799A (V600E).
- There was no association between BRAF mutation,
immunological markers of tumor characteristics, lymph node metastasis
and Thyroglobulin concentration.
2. Among patients studied, patients with BRAF mutation V600E had a
higher recurrence rate (91.7% compared to 8.3%) without mutation (p =
0.02).
- Among the studied patients, female patients had higher
recurrence rates than male patients (p = 0.02).
- In the study patients, the average time of metastasis appeared
in the group of patients with BRAF V600E gene mutation earlier than
the group of patients without mutations (p = 0.01).
+ In the study patients, the average time of metastasis appeared in
the group of male patients earlier than the female patient group (p = 0.02).
- Cox model analysis showed that patients mutating BRAF
V600E gene would increase the risk of recurrence by 9.14 times (p =
0.04, log-rank test) compared to the group without mutation.