Evaluation of Anaplastic thyroid carcinoma in the Kurdistan Region of Iraq

Evaluation of Anaplastic thyroid carcinoma in the Kurdistan Region of Iraq | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Anaplastic thyroid carcinoma in the Kurdistan Region of Iraq Dilshad Hamad Mustafa, Baderkhan Saeed Ahmed, Rawand Musheer Haweizy, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1687784/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Anaplastic thyroid carcinoma is a rare and lethal disease that accounts for 1–2% of thyroid malignancies. It is an aggressive locoregional disease, with a high rate of distant metastasis, a poor prognosis, and a mean survival rate of 3–6 months after diagnosis. The aim of this retrospective study is to analyse clinical and pathological features of ATC in order to assess treatment procedures and its outcome. Methods: We analysed data from 22 patients diagnosed with ATC in the period from 2018 to 2021, using the Kaplan-Meier method and log-rank test to determine overall survival. Results: Patients’ median age was 64.3 ± 17.1 years. Females were more affected (male/female ratio: 1:1.7); 14 cases occurred in females (63.6.4%), and eight in males (36.4%). The most common manifestations were neck enlargement (81.8%) and dyspnoea (72.27%), and the tumour size was > 4cm in 17 (77.3%) patients. The percentage of cases that presented in clinical-stage IVA was 36.4%, with 31.8% presenting in clinical-stage IVB, and 31.8% presenting in clinical-stage VIB. Among 22 cases, 14 (63.6%) were operable, and 8 (36.4) were inoperable (p=0.015). Multimodal therapies were associated with better survival (surgery plus radiotherapy without systemic treatment, P = 0.063). The median overall survival was three months (IC 95%, 0.078–5.922). One-year and two-year survival rates were 9% and 4.5%, respectively. Conclusions: ATC is a rapidly growing cancer that fortunately is rare. Early diagnosis and multimodality treatment may provide a better quality of life and survival time for this group of patients. Anaplastic thyroid carcinoma surgery multimodal therapy prognosis survival Kurdistan region Iraq Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Anaplastic thyroid carcinoma (ATC) is an uncommon but profoundly aggressive thyroid malignancy established in undifferentiated follicular thyroid cells [ 1 , 2 ]. It accounts for more than 50% of all deaths attributable to thyroid tumours, with a mean survival period of three to four months, and disease-specific mortality at one year of about 100% [ 1 , 3 ]. ATC prevalence varies from one place to another, with higher rates in goitre-endemic areas; in the USA it accounts for 1.7% of all thyroid malignancies, ranging from 1.3–9.8% [ 4 ]. It is commonly diagnosed in elderly persons (the mean age at diagnosis is 65–70 years), and there is a slightly higher female prevalence [ 5 ]. The yearly frequency of ATC is roughly one-to-two cases per million people. Risk factors for the development of ATC include a history of radiation to the neck or chest, long-standing goitre, progressed age, and a history of benign or malignant thyroid disease [ 6 ]. Patients with ATC encounter noteworthy nearby compressive symptoms due to a quickly advancing central neck mass (77%), accompanying dysphagia (40%), hoarseness (40%), and stridor (24%). Metastases are well known in 50% of patients at the time of diagnosis, most commonly in the lungs (80%), bone (6–16%), and brain (5–13%) [ 7 , 8 ]. The diagnostic modality for ATC is fine needle aspiration cytology (FNAC). In doubtful cases, the diagnosis is made by histology on a tissue biopsy [ 9 ]. Because of its aggressive behaviour and low chance of recovery, ATC is classified according to the American Joint Committee on Cancer TNM (AJCC-8) system as T4 and stage IV [ 10 , 11 ]. To assess the advance of tumour attack and lymph node metastasis absolutely, contrast-enhanced neck computed tomography (CT) is suggested. For the assessment of far-off metastases, fluorodeoxyglucose (FDG) positron emission tomography (PET) and brain magnetic resonance imaging (MRI) are commonly prescribed [ 12 ]. Multidisciplinary healthcare teams (comprising surgeons, radiation oncologists, medical oncologists, psychologists, and nurses, among others) are inherently involved in ATC treatment, and interdisciplinary communication and collaborative working can represent a significant challenge during ATC management. A significant number of ATC patients are non-operable at the time of diagnosis of their cancer, and within the subset of patients with operable disease at the time of diagnosis, surgery combined with postoperative radiation +/- chemotherapy may be useful [ 1 , 13 ]. The purpose of this study is to retrospectively analyse clinical and pathological features of ATC in order to assess treatment procedures and outcomes. Methods Patients and methods In this retrospective study, 700 cases of thyroid cancer were examined from the 1st of June, 2018, to the 31st of December, 2021), out of which 22 were included as cases of ATC. The data were obtained from various hospitals and health care centre (Rizgary, Nanakaky, Hewa, and Azadi Teaching Hospitals, with their oncologic units) throughout the main cities of the Kurdistan Region (Erbil, Sulaymaniyah, and Duhok), in northern Iraq. All 22 cases were pathologically diagnosed as ATC, depending on FNAC and excisional biopsy. Preoperative investigation documentation such as that concerning laryngoscopy, neck ultrasonography, and CT of the head, neck, chest, and abdomen were examined to detect the extent of tumour invasion. Two conditions comprised exclusion criteria: poorly differentiated thyroid cancer, and patients’ refusal to participate. A questionnaire was administered to record participants’ demographic characteristics (age, sex, place of residence) and their clinical presentation, diagnostic procedures, therapeutic approaches and outcomes, and survival. Additional data was collected from patients’ relatives by direct interviewing or calling. Prognostic factors like survival rates by age, tumour size, presence of distant metastasis, and treatment were calculated. The guidelines of the American Joint Committee on Cancer were used for staging: tumour (T), nodal (N), and distant metastasis (M). This study is part of an ongoing Ph.D. research project sponsored by the College of Medicine at Hawler Medical University. It was approved by the Ethical Committee in the College of Medicine (meeting code: 6, paper code: 6, date: 27/04/2022). Statistical analysis Data were analysed using SPSS version 25. Numerical variables were summarized by calculating the means and the standard deviations (SDs). Categorical variables were presented in the form of frequencies and proportions. Kaplan-Meier survival analysis was applied, and Log Rank (Mantel-Cox) test was used to compare the survival curves of the studied variables (like age, gender, grading, and size etc.). A P value of ≤ 0.05 was considered as statistically significant. Results A total of 22 patients agreed to take part in this study, comprising 14 females (63.6%) and 8 males (36.4%). The male-to-female ratio was 1:1.7. The mean age was 64.3±17.1 years, ranging from 26–87 years. The majority (n = 14, 63.6%) were aged ≥ 60 years. The most common clinical presentation was presence of swelling in lower part of anterior neck, which was observed in 18 (81.8%) patients, and it was bilateral in a third of them (n = 6, 33.3%). More than a third (n = 8, 36.4%) of patients were stage A, and the tumour size was > 4 cm in 17 (77.3%) patients. The majority (n = 20, 90.9%) of patients were diagnosed by FNAC, and the rest (n = 2, 9.1%) by excisional biopsy as ATC. The ATC-related clinical characteristics of participants are shown in Table 1. Table 1 Characteristics of patients with ATC No. (%) Mean (SD) Median Min. Max. Gender Male 8 (36.4) Female 14 (63.6) Age at diagnosis 64.3 (17.1) 68.0 26.0 87.0 < 60 years 8 36.4 ≥ 60 years 14 63.6 Clinical presentation Lump 18 (81.8) Pain 3 (13.6) Dyspnoea 16 (72.7) Dysphagia 10 (45.5) Hoarseness of voice 9 (40.9) Stridor 2 (9.1) Site of lump 18 Right 4 (22.2) Left 4 (22.2) Bilateral 6 (33.3) Diffuse 4 (22.2) Staging A. Local infiltration 8 (36.4) B. Regional involvement of lymph nodes 7 (31.8) C. Distant metastasis 7 (31.8) Tumour size 5.8 (2.0) 5.7 3 12 ≤ 4 cm 5 (22.7) > 4 cm 17 (77.3) WBC 8911 (4354) 8350 2800 18000 Fine needle aspiration Indeterminate* 2 (9.1) Malignant (anaplastic) 20 (90.9) Total 22 (100.0) *Proved post-operatively by tissue biopsy to be malignant. Different methods were used for the treatment of the 22 included cases, of which 14 (63.6%) were operable. Equal proportions of patients received total thyroidectomy and neck dissection or surgery and radiotherapy (n = 6, 27.3% each). Further supportive interventions such as tracheostomy were undertaken for 3 (13.6%) patients due to airway obstruction, and one (4.5%) patient had percutaneous endoscopic gastrostomy. Participants’ therapeutic modalities are described in Table 2. Table 2 Treatment modalities No. %) Type of surgery Lobectomy 4 (18.2) Subtotal thyroidectomy 1 (4.5) Total thyroidectomy 6 (27.3) Debulking 3 (13.6) Inoperable 8 (36.4) Type of neck dissection (n = 6) Central 3 (50.0) Central and lateral 3 (50.0) Type of therapy Chemotherapy 2 (9.1) Radiotherapy 1 (4.5) Surgery 4 (18.2) The mean survival rate was 5.5 months, and the median was 3.0 months. Two (9%) patients who got thyroidectomy, chemotherapy and radiotherapy lived longer than one year, of whom only one case (4.5%) was alive without any evidence of recurrence of the disease at 40-month follow-up. There was no significant association between survival rate in relation to the age ( P = 0.805) and gender ( P = 0.103) (Table 3, Fig. 1, Fig. 2) Table 3 Survival by age and gender Mean Median 95% Confidence Interval 95% Confidence Interval P* Estimate SE Lower Bound Upper Bound Estimate SE Lower Bound Upper Bound Age (y) < 60 5.16 1.74 1.75 8.57 4.00 3.67 0.00 11.20 ≥ 60 5.71 1.54 2.68 8.74 3.00 0.92 1.18 4.81 0.805 Gender Male 3.16 1.24 0.71 5.61 1.00 Female 6.57 1.54 3.55 9.58 4.00 1.87 0.33 7.66 0.103 Overall 5.55 1.17 3.24 7.85 3.00 1.49 0.07 5.92 *By Log Rank (Mantel-Cox) There was no significant association between survival of patients with tumour grade ( P = 0.441) and White blood cell (WBC) count ( P = 0.104), as shown in Table 4, and Fig. 3, Fig. 4. Significant associations were found between tumour size ( P = 0.006) and operability (P = 0.015) and patient survival (Table 4, Fig. 5, Fig. 6). There was no significant association between all treatment modalities and survival rate ( P = 0.063) (Table 4, Fig. 7). Table 4 Survival by characteristics and treatment of ATC Mean Median1` 95% Confidence Interval 95% Confidence Interval P* Estimate SE Lower Bound Estimate SE Lower Bound Upper Bound Grading A 7.42 2.17 3.17 11.68 7.00 1.30 4.43 9.56 B 3.71 1.30 1.15 6.27 2.00 0.43 1.14 2.85 C 5.50 2.64 0.32 10.67 2.00 1.83 0.00 5.60 0.441 Size ≤ 4 cm 1.50 0.28 0.93 2.06 1.00 > 4 cm 6.56 1.36 3.89 9.22 5.00 2.00 1.08 8.92 0.006 WBCs <10000 6.84 1.60 3.69 9.99 5.00 2.39 0.30 9.69 ≥10000 3.14 1.20 0.78 5.50 2.00 0.39 1.21 2.78 0.104 Intervention Operable 7.41 1.73 4.00 10.82 7.00 2.30 2.47 11.52 Non-operable 2.75 0.64 1.48 4.02 2.00 0.45 1.10 2.89 0.015 Type of therapy Chemo-therapy 3.500 2.500 0.000 8.400 1.000 Radio-therapy 2.000 0.000 2.000 2.000 2.000 Surgery 3.250 1.797 0.000 6.772 1.000 2.000 0.000 4.920 Chemo and radio 3.000 0.707 1.614 4.386 2.000 Multiple modality 9.500 7.500 0.000 24.200 2.000 Sympto-matic treatment 1.000 0.000 1.000 1.000 1.000 Radio surgery therapy 9.500 2.187 5.213 13.787 8.000 1.225 5.600 10.400 0.063 Overall 5.550 1.178 3.242 7.858 3.000 1.491 0.078 5.922 *By Log Rank (Mantel-Cox) Discussion Anaplastic thyroid carcinoma is one of the fastest-growing tumours in humans, with local invasion and a high rate of distant metastasis. It has a poor prognosis, with a mean survival rate of 3–6 months after diagnosis [ 14 , 15 ]. However, according to the data available, it is one of the uncommon malignancies of humanity. In the current study, the incidence of ATC was 3.15% of all cases of thyroid cancer, and the overall survival rate was 5.5 months. Females are known to be more prone to thyroid disease in general, and cancers in particular; in our study, which selected ATC patients randomly, females comprised 63.6% of the sample (with a male-to-female ratio of 1:1.7), which is in accordance with published data in different national contexts [ 16 , 17 , 18 ]. The majority of patients were aged over 60 years (63.6%), reflecting the association of age with the oncological process, including ATC [ 5 ]. This is related to the effect of tumour suppressor gene inhibition in older age, apparently as part of the natural aging process [ 19 ]. According to published literature, local symptoms of ATC most commonly begin with a rapidly evolving central neck mass (77%), followed by noticeable dysphagia (40%), voice change or hoarseness (40%), and stridor (24%) [ 7 , 8 ]. Our study showed similar results in the way in which the majority of patients (81.8%) presented with compressive symptoms. The disease progression to surrounding tissues is one of the most important aspects of pathophysiology, since it has a direct impact on both the treatment and prognosis. In our observation stage, IVB + IVC was about 63.6%, and studies of rapid extension to surrounding tissues have reported that 80% of ATC patients have disease in both thyroid and nearby tissues at their initial presentation [ 1 , 4 – 8 , 20 ]. However, the survival duration of our cases with stage IVB + IVC was not so different from group A, who lived for 3–11 months, while those in Groups B and C lived for 2 weeks to 10 months (with a median of 2 months). Three months is commonly reported to be the median survival window [ 21 ]. The relatively shorter duration of survival in our study (2 months) could be explained by the delayed diagnosis and modality of treatments in the studied cases. Participants’ tumour size was > 4 cm among the majority (77.3%) of participants. Previous studies reported tumours ranging between 3.6–10.5 cm, but only 68.9% of cases were reported to be larger than 4 cm [ 16 , 22 ]. Despite the fact that larger tumour sizes are bad prognostic factors [ 22 ], those with larger tumours survived longer than those with smaller ones in the current study. This discrepancy could be explained by the role of large size in increasing patient awareness and motivation to seek treatment at an earlier stage, thereby increasing the scope of treatment and survival prospects. One of the prognostic factors in ATC is the level of WBC. A patient with a WBC level of less than 10000 /µL has a better prognosis in regard to the duration of survival, and may live 11.3 months, compared to patients with leucocytosis who average 3.6 months [ 23 , 24 ]. In our study, the difference between the leucocytosis and non-leucocytosis group was not statistically significant, but there was a difference in the survival window (2 weeks to 9 months for non-leucocytosis, and 2 weeks to 3 months for leucocytosis patients). Thus, the total body reaction in the form of leucocytosis may adversely affect the survival duration. The FNAC as a diagnostic tool in ATC has good support for its range of accuracy: 89.71% accuracy in diagnosis for 94.7% of ATC cases diagnosed by FNAC [ 25 ]. In our study, FNAC was used for all patients and it was accurate in 20 (90.9%) cases as a diagnostic tool, given that all of our cases were included and based on histopathological reports that assured the accuracy of FNAC for such malignancy. Surgery is one of the best options for the patients either to remove the tumour completely or to improve its local effects, like airway compression. However, in small, non-extended tumours it could be regarded as a curative for a short duration, with potential application as a palliative measure in inoperable patients, but it could potentially extend survival outcomes in the case of surgery combined with chemoradiation [ 22 ]. This study found that surgery showed a better median survival time of 7 months for operated cases, compared to 2 months for non-operable ones; and the 9% of patients who lived more than one year (a remarkable duration for ATC patients) were those who had undergone surgery as a part of treatment (in addition to chemoradiotherapy). The main treatment modality in the group of patients with local and distant metastasis was adjuvant therapy, with or without debulking. Trials for different chemotherapy variants do not significantly change the duration of surviving in ATC [ 26 ], but hypofractionated radiotherapy showed positive results in prolonging the median survival duration in this category of patients [ 27 ]. Single modality treatment does not show good prognostic effects; although surgery was one of the mainstays of treatment, in itself (without additional treatment) it only achieved a 2-month survival rate. Similarly, radiotherapy and chemotherapy when used alone achieved 2 and 3.5 months of survival, respectively. Conversely, multimodal treatment extended the survival window to 9.5 months – in particular, this was achieved by surgery in combination with radiotherapy (combined without chemotherapy). The combination of chemotherapy and radiotherapy without surgery only produced a mean survival time of 3 months. Conclusions ATC and its treatment in the Kurdistan Region exhibit the same tendencies as elsewhere in the world, and this study shows the superiority of early diagnosis and multimodality treatment as two main important factors that may provide better survival rate. However, this study is limited by its small number of cases, and its retrospective nature limits the approach with regard to many specific issues of concern for such a pathology. At the same time, local specifications like the inaccessibility of radiotherapy and chemotherapy shortly after surgery, and the lack of proper awareness and screening programs in the country, make the diagnosis and prognosis of this pathology much worse than it could be. ATC is a rapidly growing cancer that fortunately is rare. Early diagnosis and multimodality treatment may provide better quality of life and survival time for patients, and awareness of this among healthcare decision makers in the Kurdistan Region should be encouraged to increase screening and healthcare-seeking behaviour among the public. Abbreviations COVID-19: Coronavirus disease ATC: Anaplastic thyroid carcinoma FNAC: Fine needle aspiration cytology AJCC: American joint committee on cancer CT: Computed tomography FDG: Fluorodeoxyglucose PET: Positron emission tomography MRI: Magnetic resonance imaging SD: Standard deviations Declarations Ethics approval and consent to participate This study was approved by the Research Ethics Committee of Hawler Medical University. All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all study subjects, Consent for publication Not applicable. Availability of the data and materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Funding Not applicable. Author’s contributions DHM conceived the study, carried out data collection and analysis and contributed to drafting the manuscript. BSA contributed to conceiving the study, project supervision, data collection and revising the manuscript. RMH and AMD contributed to designing the study, data collection and drafting the manuscript. All authors have read and approved the final draft of the manuscript. Acknowledgments The authors thank all patients, their families and caregivers for providing clinical data for this study.. Competing interests The author declares that he has no competing interests. References Smallridge RC, Ain KB, Asa SL, Bible KC, Brierley JD, Burman KD, Kebebew E, Lee NY, Nikiforov YE, Rosenthal MS, Shah MH. American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid. 2012 Nov 1;22(11):1104-39. Xiang J, Wang Z, Sun W, Zhang H. A relook at the 8th edition of the AJCC TNM staging system of anaplastic thyroid carcinoma: A SEER‐based study. Clinical Endocrinology. 2021 Apr;94(4):700-10. Simões-Pereira J, Capitão R, Limbert E, Leite V. Anaplastic thyroid cancer: clinical picture of the last two decades at a single oncology referral centre and novel therapeutic options. Cancers. 2019 Aug;11(8):1188. O'Neill JP, Shaha AR. Anaplastic thyroid cancer. Oral Oncol. 2013 Jul;49(7):702-6. doi: 10.1016/j.oraloncology.2013.03.440. Epub 2013 Apr 11. PMID: 23583302. Wong KS, Lorch JH, Alexander EK, Marqusee E, Cho NL, Nehs MA, Doherty GM, Barletta JA. Histopathologic features and clinical outcome of anaplastic thyroid carcinoma with a minor anaplastic component. Endocrine Pathology. 2020 Sep;31(3):283-90. Patel S, Goldenberg D, Bann DV. The role of surgery in the management of anaplastic thyroid carcinoma. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2021 Jun 1;32(2):e27-31. Nagaiah G, Hossain A, Mooney CJ, Parmentier J, Remick SC. Anaplastic thyroid cancer: a review of epidemiology, pathogenesis, and treatment. Journal of oncology. 2011 Oct;2011. Zalzal HG, Chung J, Perini JA. Remarkable Presentation: Anaplastic Thyroid Carcinoma Arising from Chronic Hyperthyroidism. Case Reports in Endocrinology. 2018 Apr 1;2018. Haddad RI, Lydiatt WM, Ball DW, Busaidy NL, Byrd D, Callender G, Dickson P, Duh QY, Ehya H, Haymart M, Hoh C. Anaplastic thyroid carcinoma, version 2.2015. Journal of the National Comprehensive Cancer Network. 2015 Sep 1;13(9):1140-50. Sobin LH, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumours: John Wiley & Sons; 2011. Onoda N, Sugitani I, Ito KI, Suzuki A, Higashiyama T, Fukumori T, Suganuma N, Masudo K, Nakayama H, Uno A, Yane K. Evaluation of the 8th edition TNM classification for anaplastic thyroid carcinoma. Cancers. 2020 Mar;12(3):552.12(3), p.552. Bible KC, Kebebew E, Brierley J, Brito JP, Cabanillas ME, Clark Jr TJ, Di Cristofano A, Foote R, Giordano T, Kasperbauer J, Newbold K. 2021 american thyroid association guidelines for management of patients with anaplastic thyroid cancer: American thyroid association anaplastic thyroid cancer guidelines task force. Thyroid. 2021 Mar 1;31(3):337-86. Xia Q, Wang W, Xu J, Chen X, Zhong Z, Sun C. Evidence from an updated meta-analysis of the prognostic impacts of postoperative radiotherapy and chemotherapy in patients with anaplastic thyroid carcinoma. OncoTargets and therapy. 2018;11:2251. Kebebew E, Greenspan FS, Clark OH, Woeber KA, McMillan A. Anaplastic thyroid carcinoma: treatment outcome and prognostic factors. Cancer. 2005 Apr 1;103(7):1330-5. Liu TR, Xiao ZW, Xu HN, Long Z, Wei FQ, Zhuang SM, Sun XM, Xie LE, Mu JS, Yang AK, Zhang GP. Treatment and prognosis of anaplastic thyroid carcinoma: a clinical study of 50 cases. PLoS One. 2016 Oct 19;11(10):e0164840. Jiang JY, Tseng FY. Prognostic factors of anaplastic thyroid carcinoma. Journal of endocrinological investigation. 2006 Jan;29(1):11-7. Gilliland FD, Hunt WC, Morris DM, Key CR. Prognostic factors for thyroid carcinoma: A population‐based study of 15,698 cases from the Surveillance, Epidemiology and End Results (SEER) Program 1973–1991. Cancer: Interdisciplinary International Journal of the American Cancer Society. 1997 Feb 1;79(3):564-73. Agrawal S, Rao RS, Parikh DM, Parikh HK, Borges AM, Sampat MB. Histologic trends in thyroid cancer 1969–1993: a clinico‐pathologic analysis of the relative proportion of anaplastic carcinoma of the thyroid. Journal of surgical oncology. 1996 Dec;63(4):251-5. Xu Z, Taylor JA. Genome-wide age-related DNA methylation changes in blood and other tissues relate to histone modification, expression and cancer. Carcinogenesis. 2014 Feb 1;35(2):356-64. Ito Y, Onoda N, Okamoto T. The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: core questions and recommendations for treatments of thyroid cancer. Endocrine journal. 2020: EJ20-0025. Lim SM, Shin SJ, Chung WY, Park CS, Nam KH, Kang SW, Keum KC, Kim JH, Cho JY, Hong YK, Cho BC. Treatment outcome of patients with anaplastic thyroid cancer: a single center experience. Yonsei medical journal. 2012 Mar 1;53(2):352-7. Kasemsiri P, Chaisakgreenon P, Vatanasapt P, Laohasiriwong S, Teeramatwanich W, Thongrong C, Ratanaanekchai T, Suetrong S. Survival Benefit of Intervention Treatment in Advanced Anaplastic Thyroid Cancer. International Journal of Surgical Oncology. 2021 Jun 3;2021. Masui T, Uemura H, Ota I, Kimura T, Nishikawa D, Yamanaka T, Yane K, Kitahara T. A study of 17 cases for the identification of prognostic factors for anaplastic thyroid carcinoma. Molecular and Clinical Oncology. 2021 Jan 1;14(1):1-. Akaishi J, Sugino K, Kitagawa W, Nagahama M, Kameyama K, Shimizu K, Ito K, Ito K. Prognostic factors and treatment outcomes of 100 cases of anaplastic thyroid carcinoma. Thyroid. 2011 Nov 1;21(11):1183-9. Us-Krasovec M, Golouh R, Auersperg M, Besic N, Ruparcic-Oblak L. Anaplastic thyroid carcinoma in fine needle aspirates. Acta cytologica. 1996 Sep 1;40(5):953-8. Sun C, Li Q, Hu Z, He J, Li C, Li G, Tao X, Yang A. Treatment and prognosis of anaplastic thyroid carcinoma: experience from a single institution in China. PloS one. 2013 Nov 5;8(11):e80011. Oliinyk D, Augustin T, Koehler VF, Rauch J, Belka C, Spitzweg C, Käsmann L. Hypofractionated radiotherapy for anaplastic thyroid cancer: Systematic review and pooled analysis. Cancers. 2020 Sep;12(9):2506. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 20 Jul, 2022 Reviews received at journal 13 Jul, 2022 Reviewers agreed at journal 04 Jul, 2022 Reviewers invited by journal 19 Jun, 2022 Editor assigned by journal 19 Jun, 2022 Editor invited by journal 09 Jun, 2022 Submission checks completed at journal 09 Jun, 2022 First submitted to journal 24 May, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1687784","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":112285702,"identity":"b962e611-4614-4097-a33d-32ea4dcbd4e8","order_by":0,"name":"Dilshad Hamad Mustafa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYDCCw8wNzAwMzHIGYB4bA4MEA4MBAS2MYC3GJGg5ANGSuIFoLXzHGZs/F9RYp28XO2PA8KHsMIPk7MMb8GqRPMzYJj3jWHruztk5Bowzzh1mkOZLK8CrxQCohZmH7XDuhts5Bsy8bYcZ5Hh48DsMqKX5M8+/w+kGIC1/idTSIA00PAGshRGoRZqQFrBfePvSDTfcTis42HMunUeyhw2/X/jOHz78meebtbzB7eSND36UWctJnGHGH2Io4AAQ8xCvfBSMglEwCkYBTgAAfEtEEf+gGo8AAAAASUVORK5CYII=","orcid":"","institution":"Hawler Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Dilshad","middleName":"Hamad","lastName":"Mustafa","suffix":""},{"id":112285703,"identity":"3c4c7414-1010-4803-ad90-8440c43a48cf","order_by":1,"name":"Baderkhan Saeed Ahmed","email":"","orcid":"","institution":"Hawler Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Baderkhan","middleName":"Saeed","lastName":"Ahmed","suffix":""},{"id":112285704,"identity":"a4b675ed-0eaf-429d-a13f-a746518d3d90","order_by":2,"name":"Rawand Musheer Haweizy","email":"","orcid":"","institution":"Hawler Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rawand","middleName":"Musheer","lastName":"Haweizy","suffix":""},{"id":112285705,"identity":"91e5e880-f3fe-4640-9f94-2ce937df3657","order_by":3,"name":"Azhy Muhammed Rwandizy","email":"","orcid":"","institution":"Hawler Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Azhy","middleName":"Muhammed","lastName":"Rwandizy","suffix":""}],"badges":[],"createdAt":"2022-05-24 08:44:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1687784/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1687784/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":22641921,"identity":"987b91df-5a10-44b0-a654-0f070eb7ef28","added_by":"auto","created_at":"2022-06-14 15:58:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":24762,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvival by age.\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-1687784/v1/adc0da532b11a256ed59cb43.png"},{"id":22641927,"identity":"96060f87-855b-4a9a-9a7c-ed9136b305db","added_by":"auto","created_at":"2022-06-14 15:58:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23817,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvival by gender.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-1687784/v1/65f6f6e2b1b28736205e2c35.png"},{"id":22641925,"identity":"d3a20b2a-25da-485b-b97f-5648993dbc1f","added_by":"auto","created_at":"2022-06-14 15:58:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":23815,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvival by grading.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-1687784/v1/fcc90fb1f32f431ae3372f23.png"},{"id":22641920,"identity":"5848fbea-f3bb-47c9-b578-ccedff693545","added_by":"auto","created_at":"2022-06-14 15:58:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":23792,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvival by WBC count\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-1687784/v1/54be9bdc55fe000e2afba9ce.png"},{"id":22641924,"identity":"2879973b-f312-48fb-b623-5b2ee82090d0","added_by":"auto","created_at":"2022-06-14 15:58:20","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":23770,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvival by tumor size.\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-1687784/v1/a40602c516b0fb00664afa45.png"},{"id":22641923,"identity":"5dce0688-0920-4e82-8089-86d037dafc00","added_by":"auto","created_at":"2022-06-14 15:58:20","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":21461,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvival by intervention.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-1687784/v1/7242674a7358eeb75368715e.png"},{"id":22641919,"identity":"ea371e69-d9fc-432e-bd41-0234de587b91","added_by":"auto","created_at":"2022-06-14 15:58:19","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":39938,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSurvival by type of therapy\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-1687784/v1/157dff55de37aaec1d7fcc29.png"},{"id":22641947,"identity":"db7bcfa0-ce78-41e1-b8e9-8aaed71eeaba","added_by":"auto","created_at":"2022-06-14 15:58:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":671998,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1687784/v1/85a641ce-2178-4e41-8b3b-f81623046b5f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Anaplastic thyroid carcinoma in the Kurdistan Region of Iraq","fulltext":[{"header":"Background","content":"\u003cp\u003eAnaplastic thyroid carcinoma (ATC) is an uncommon but profoundly aggressive thyroid malignancy established in undifferentiated follicular thyroid cells [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It accounts for more than 50% of all deaths attributable to thyroid tumours, with a mean survival period of three to four months, and disease-specific mortality at one year of about 100% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. ATC prevalence varies from one place to another, with higher rates in goitre-endemic areas; in the USA it accounts for 1.7% of all thyroid malignancies, ranging from 1.3\u0026ndash;9.8% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It is commonly diagnosed in elderly persons (the mean age at diagnosis is 65\u0026ndash;70 years), and there is a slightly higher female prevalence [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The yearly frequency of ATC is roughly one-to-two cases per million people.\u003c/p\u003e \u003cp\u003eRisk factors for the development of ATC include a history of radiation to the neck or chest, long-standing goitre, progressed age, and a history of benign or malignant thyroid disease [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Patients with ATC encounter noteworthy nearby compressive symptoms due to a quickly advancing central neck mass (77%), accompanying dysphagia (40%), hoarseness (40%), and stridor (24%). Metastases are well known in 50% of patients at the time of diagnosis, most commonly in the lungs (80%), bone (6\u0026ndash;16%), and brain (5\u0026ndash;13%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnostic modality for ATC is fine needle aspiration cytology (FNAC). In doubtful cases, the diagnosis is made by histology on a tissue biopsy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Because of its aggressive behaviour and low chance of recovery, ATC is classified according to the American Joint Committee on Cancer TNM (AJCC-8) system as T4 and stage IV [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo assess the advance of tumour attack and lymph node metastasis absolutely, contrast-enhanced neck computed tomography (CT) is suggested. For the assessment of far-off metastases, fluorodeoxyglucose (FDG) positron emission tomography (PET) and brain magnetic resonance imaging (MRI) are commonly prescribed [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMultidisciplinary healthcare teams (comprising surgeons, radiation oncologists, medical oncologists, psychologists, and nurses, among others) are inherently involved in ATC treatment, and interdisciplinary communication and collaborative working can represent a significant challenge during ATC management. A significant number of ATC patients are non-operable at the time of diagnosis of their cancer, and within the subset of patients with operable disease at the time of diagnosis, surgery combined with postoperative radiation +/- chemotherapy may be useful [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe purpose of this study is to retrospectively analyse clinical and pathological features of ATC in order to assess treatment procedures and outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients and methods\u003c/h2\u003e \u003cp\u003eIn this retrospective study, 700 cases of thyroid cancer were examined from the 1st of June, 2018, to the 31st of December, 2021), out of which 22 were included as cases of ATC. The data were obtained from various hospitals and health care centre (Rizgary, Nanakaky, Hewa, and Azadi Teaching Hospitals, with their oncologic units) throughout the main cities of the Kurdistan Region (Erbil, Sulaymaniyah, and Duhok), in northern Iraq. All 22 cases were pathologically diagnosed as ATC, depending on FNAC and excisional biopsy.\u003c/p\u003e \u003cp\u003ePreoperative investigation documentation such as that concerning laryngoscopy, neck ultrasonography, and CT of the head, neck, chest, and abdomen were examined to detect the extent of tumour invasion. Two conditions comprised exclusion criteria: poorly differentiated thyroid cancer, and patients\u0026rsquo; refusal to participate. A questionnaire was administered to record participants\u0026rsquo; demographic characteristics (age, sex, place of residence) and their clinical presentation, diagnostic procedures, therapeutic approaches and outcomes, and survival. Additional data was collected from patients\u0026rsquo; relatives by direct interviewing or calling.\u003c/p\u003e \u003cp\u003ePrognostic factors like survival rates by age, tumour size, presence of distant metastasis, and treatment were calculated. The guidelines of the American Joint Committee on Cancer were used for staging: tumour (T), nodal (N), and distant metastasis (M).\u003c/p\u003e \u003cp\u003eThis study is part of an ongoing Ph.D. research project sponsored by the College of Medicine at Hawler Medical University. It was approved by the Ethical Committee in the College of Medicine (meeting code: 6, paper code: 6, date: 27/04/2022).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were analysed using SPSS version 25. Numerical variables were summarized by calculating the means and the standard deviations (SDs). Categorical variables were presented in the form of frequencies and proportions. Kaplan-Meier survival analysis was applied, and Log Rank (Mantel-Cox) test was used to compare the survival curves of the studied variables (like age, gender, grading, and size etc.). A \u003cem\u003eP\u003c/em\u003e value of \u0026le;\u0026thinsp;0.05 was considered as statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 22 patients agreed to take part in this study, comprising 14 females (63.6%) and 8 males (36.4%). The male-to-female ratio was 1:1.7. The mean age was 64.3\u0026plusmn;17.1 years, ranging from 26\u0026ndash;87 years. The majority (n = 14, 63.6%) were aged \u0026ge; 60 years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe most common clinical presentation was presence of swelling in lower part of anterior neck, which was observed in 18 (81.8%) patients, and it was bilateral in a third of them (n = 6, 33.3%). More than a third (n = 8, 36.4%) of patients were stage A, and the tumour size was \u0026gt; 4 cm in 17 (77.3%) patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority (n = 20, 90.9%) of patients were diagnosed by FNAC, and the rest (n = 2, 9.1%) by excisional biopsy as ATC. The ATC-related clinical characteristics of participants are shown in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eCharacteristics of patients with ATC\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse: collapse; margin: 0px auto;\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMax.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(63.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at diagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e64.3 (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e87.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ge; 60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;63.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical presentation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLump\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDyspnoea \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDysphagia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHoarseness of voice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(40.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStridor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Site of lump\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLeft\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiffuse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA. Local infiltration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB. Regional involvement of lymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC. Distant metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumour size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.8 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026le; 4 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026gt; 4 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(77.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWBC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8911 (4354)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFine needle aspiration\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Indeterminate*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Malignant (anaplastic)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(90.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Proved post-operatively by tissue biopsy to be malignant.\u003c/p\u003e\n\u003cp\u003eDifferent methods were used for the treatment of the 22 included cases, of which 14 (63.6%) were operable. Equal proportions of patients received total thyroidectomy and neck dissection or surgery and radiotherapy (n = 6, 27.3% each). Further supportive interventions such as tracheostomy were undertaken for 3 (13.6%) patients due to airway obstruction, and one (4.5%) patient had percutaneous endoscopic gastrostomy. Participants\u0026rsquo; therapeutic modalities are described in Table 2.\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTreatment modalities\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e\u003cstrong\u003e%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eLobectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eSubtotal thyroidectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eTotal thyroidectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eDebulking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eInoperable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of neck dissection (n = 6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eCentral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eCentral and lateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eChemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eRadiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"43.43434343434343%\"\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.22222222222222%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"34.343434343434346%\"\u003e\n \u003cp\u003e(18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean survival rate was 5.5 months, and the median was 3.0 months. Two (9%) patients who got thyroidectomy, chemotherapy and radiotherapy lived longer than one year, of whom only one case (4.5%) was alive without any evidence of recurrence of the disease at 40-month follow-up.\u0026nbsp;There was no significant association between survival rate in relation to the age (\u003cem\u003eP\u003c/em\u003e = 0.805) and gender (\u003cem\u003eP\u003c/em\u003e = 0.103) (Table 3, Fig. 1, Fig. 2)\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eSurvival by age and gender\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10.204081632653061%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.16326530612245%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"20.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"20.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpper Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpper Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (y)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u0026lt; 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e5.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e1.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e8.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e11.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u0026ge; 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e5.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e8.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e4.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.805\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e3.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e5.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e6.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e3.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e9.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e1.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e7.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.103\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e5.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e7.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.5%\"\u003e\n \u003cp\u003e3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.291666666666667%\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"10.416666666666666%\"\u003e\n \u003cp\u003e5.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"8.333333333333334%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*By Log Rank (Mantel-Cox)\u003c/p\u003e\n\u003cp\u003eThere was no significant association between survival of patients with tumour grade (\u003cem\u003eP\u003c/em\u003e = 0.441) and White blood cell (WBC) count (\u003cem\u003eP\u003c/em\u003e = 0.104), as shown in Table 4, and Fig. 3, Fig. 4. Significant associations were found between tumour size (\u003cem\u003eP\u003c/em\u003e = 0.006) and operability (P = 0.015) and patient survival (Table 4, Fig. 5, Fig. 6). There was no significant association between all treatment modalities and survival rate (\u003cem\u003eP\u003c/em\u003e = 0.063) (Table 4, Fig. 7).\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Survival by characteristics and treatment of ATC\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" width=\"38.25816485225506%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" width=\"38.5692068429238%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian1`\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.264797507788161%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.682242990654206%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.94392523364486%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.69158878504673%\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.682242990654206%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.94392523364486%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"18.847352024922117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.94392523364486%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpper Bound\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrading\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e7.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e11.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e9.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e3.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e6.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e5.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e2.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e10.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e5.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.441\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSize\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u0026le; 4 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u0026gt; 4 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e6.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e3.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e9.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e8.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWBCs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u0026lt;10000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e6.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e3.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e9.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e2.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e9.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u0026ge;10000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e3.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e5.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e2.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eOperable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e7.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e10.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e7.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e11.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eNon-operable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e4.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e2.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eChemo-therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e3.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e2.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e8.400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eRadio-therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e2.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e2.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e2.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e2.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e3.250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.797\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e6.772\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e2.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e4.920\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eChemo and radio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e3.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.707\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e1.614\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e4.386\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e2.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eMultiple modality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e9.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e7.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e24.200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e2.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eSympto-matic treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003eRadio surgery therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e9.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e2.187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e5.213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e13.787\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e8.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.225\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e5.600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e10.400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.241057542768274%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e5.550\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e3.242\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.175738724727838%\"\u003e\n \u003cp\u003e7.858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.66407465007776%\"\u003e\n \u003cp\u003e3.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e1.491\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.486780715396579%\"\u003e\n \u003cp\u003e5.922\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"7.9315707620528775%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*By Log Rank (Mantel-Cox)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAnaplastic thyroid carcinoma is one of the fastest-growing tumours in humans, with local invasion and a high rate of distant metastasis. It has a poor prognosis, with a mean survival rate of 3\u0026ndash;6 months after diagnosis [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, according to the data available, it is one of the uncommon malignancies of humanity. In the current study, the incidence of ATC was 3.15% of all cases of thyroid cancer, and the overall survival rate was 5.5 months.\u003c/p\u003e \u003cp\u003eFemales are known to be more prone to thyroid disease in general, and cancers in particular; in our study, which selected ATC patients randomly, females comprised 63.6% of the sample (with a male-to-female ratio of 1:1.7), which is in accordance with published data in different national contexts [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The majority of patients were aged over 60 years (63.6%), reflecting the association of age with the oncological process, including ATC [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This is related to the effect of tumour suppressor gene inhibition in older age, apparently as part of the natural aging process [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to published literature, local symptoms of ATC most commonly begin with a rapidly evolving central neck mass (77%), followed by noticeable dysphagia (40%), voice change or hoarseness (40%), and stridor (24%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our study showed similar results in the way in which the majority of patients (81.8%) presented with compressive symptoms. The disease progression to surrounding tissues is one of the most important aspects of pathophysiology, since it has a direct impact on both the treatment and prognosis. In our observation stage, IVB\u0026thinsp;+\u0026thinsp;IVC was about 63.6%, and studies of rapid extension to surrounding tissues have reported that 80% of ATC patients have disease in both thyroid and nearby tissues at their initial presentation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, the survival duration of our cases with stage IVB\u0026thinsp;+\u0026thinsp;IVC was not so different from group A, who lived for 3\u0026ndash;11 months, while those in Groups B and C lived for 2 weeks to 10 months (with a median of 2 months). Three months is commonly reported to be the median survival window [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The relatively shorter duration of survival in our study (2 months) could be explained by the delayed diagnosis and modality of treatments in the studied cases.\u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; tumour size was \u0026gt;\u0026thinsp;4 cm among the majority (77.3%) of participants. Previous studies reported tumours ranging between 3.6\u0026ndash;10.5 cm, but only 68.9% of cases were reported to be larger than 4 cm [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Despite the fact that larger tumour sizes are bad prognostic factors [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], those with larger tumours survived longer than those with smaller ones in the current study. This discrepancy could be explained by the role of large size in increasing patient awareness and motivation to seek treatment at an earlier stage, thereby increasing the scope of treatment and survival prospects.\u003c/p\u003e \u003cp\u003eOne of the prognostic factors in ATC is the level of WBC. A patient with a WBC level of less than 10000 /\u0026micro;L has a better prognosis in regard to the duration of survival, and may live 11.3 months, compared to patients with leucocytosis who average 3.6 months [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In our study, the difference between the leucocytosis and non-leucocytosis group was not statistically significant, but there was a difference in the survival window (2 weeks to 9 months for non-leucocytosis, and 2 weeks to 3 months for leucocytosis patients). Thus, the total body reaction in the form of leucocytosis may adversely affect the survival duration.\u003c/p\u003e \u003cp\u003eThe FNAC as a diagnostic tool in ATC has good support for its range of accuracy: 89.71% accuracy in diagnosis for 94.7% of ATC cases diagnosed by FNAC [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In our study, FNAC was used for all patients and it was accurate in 20 (90.9%) cases as a diagnostic tool, given that all of our cases were included and based on histopathological reports that assured the accuracy of FNAC for such malignancy.\u003c/p\u003e \u003cp\u003eSurgery is one of the best options for the patients either to remove the tumour completely or to improve its local effects, like airway compression. However, in small, non-extended tumours it could be regarded as a curative for a short duration, with potential application as a palliative measure in inoperable patients, but it could potentially extend survival outcomes in the case of surgery combined with chemoradiation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This study found that surgery showed a better median survival time of 7 months for operated cases, compared to 2 months for non-operable ones; and the 9% of patients who lived more than one year (a remarkable duration for ATC patients) were those who had undergone surgery as a part of treatment (in addition to chemoradiotherapy).\u003c/p\u003e \u003cp\u003eThe main treatment modality in the group of patients with local and distant metastasis was adjuvant therapy, with or without debulking. Trials for different chemotherapy variants do not significantly change the duration of surviving in ATC [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], but hypofractionated radiotherapy showed positive results in prolonging the median survival duration in this category of patients [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSingle modality treatment does not show good prognostic effects; although surgery was one of the mainstays of treatment, in itself (without additional treatment) it only achieved a 2-month survival rate. Similarly, radiotherapy and chemotherapy when used alone achieved 2 and 3.5 months of survival, respectively. Conversely, multimodal treatment extended the survival window to 9.5 months \u0026ndash; in particular, this was achieved by surgery in combination with radiotherapy (combined without chemotherapy). The combination of chemotherapy and radiotherapy without surgery only produced a mean survival time of 3 months.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eATC and its treatment in the Kurdistan Region exhibit the same tendencies as elsewhere in the world, and this study shows the superiority of early diagnosis and multimodality treatment as two main important factors that may provide better survival rate. However, this study is limited by its small number of cases, and its retrospective nature limits the approach with regard to many specific issues of concern for such a pathology. At the same time, local specifications like the inaccessibility of radiotherapy and chemotherapy shortly after surgery, and the lack of proper awareness and screening programs in the country, make the diagnosis and prognosis of this pathology much worse than it could be. ATC is a rapidly growing cancer that fortunately is rare. Early diagnosis and multimodality treatment may provide better quality of life and survival time for patients, and awareness of this among healthcare decision makers in the Kurdistan Region should be encouraged to increase screening and healthcare-seeking behaviour among the public.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCOVID-19: Coronavirus disease\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eATC:\u0026nbsp;\u003c/strong\u003eAnaplastic thyroid carcinoma\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFNAC:\u0026nbsp;\u003c/strong\u003eFine needle aspiration cytology\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAJCC:\u0026nbsp;\u003c/strong\u003eAmerican joint committee on cancer\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCT:\u0026nbsp;\u003c/strong\u003eComputed tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFDG:\u003c/strong\u003e Fluorodeoxyglucose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePET:\u0026nbsp;\u003c/strong\u003ePositron emission tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRI:\u0026nbsp;\u003c/strong\u003eMagnetic resonance imaging\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSD:\u0026nbsp;\u003c/strong\u003eStandard deviations\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Research Ethics Committee of Hawler Medical University. All methods were carried out in accordance with\u0026nbsp;relevant guidelines and regulations. Informed consent was obtained from all study subjects,\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of the data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDHM conceived the study, carried out data collection and analysis and contributed to drafting the manuscript. BSA contributed to conceiving the study, project supervision, data collection and revising the manuscript. RMH and AMD contributed to designing the study, data collection and drafting the manuscript. All authors have read and approved the final draft of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all patients, their families and caregivers for providing clinical data for this study..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that he has no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSmallridge RC, Ain KB, Asa SL, Bible KC, Brierley JD, Burman KD, Kebebew E, Lee NY, Nikiforov YE, Rosenthal MS, Shah MH. American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid. 2012 Nov 1;22(11):1104-39.\u003c/li\u003e\n\u003cli\u003eXiang J, Wang Z, Sun W, Zhang H. A relook at the 8th edition of the AJCC TNM staging system of anaplastic thyroid carcinoma: A SEER‐based study. Clinical Endocrinology. 2021 Apr;94(4):700-10. \u003c/li\u003e\n\u003cli\u003eSim\u0026otilde;es-Pereira J, Capit\u0026atilde;o R, Limbert E, Leite V. Anaplastic thyroid cancer: clinical picture of the last two decades at a single oncology referral centre and novel therapeutic options. Cancers. 2019 Aug;11(8):1188. \u003c/li\u003e\n\u003cli\u003eO\u0026apos;Neill JP, Shaha AR. Anaplastic thyroid cancer. Oral Oncol. 2013 Jul;49(7):702-6. doi: 10.1016/j.oraloncology.2013.03.440. Epub 2013 Apr 11. PMID: 23583302.\u003c/li\u003e\n\u003cli\u003eWong KS, Lorch JH, Alexander EK, Marqusee E, Cho NL, Nehs MA, Doherty GM, Barletta JA. Histopathologic features and clinical outcome of anaplastic thyroid carcinoma with a minor anaplastic component. Endocrine Pathology. 2020 Sep;31(3):283-90.\u003c/li\u003e\n\u003cli\u003ePatel S, Goldenberg D, Bann DV. The role of surgery in the management of anaplastic thyroid carcinoma. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2021 Jun 1;32(2):e27-31.\u003c/li\u003e\n\u003cli\u003eNagaiah G, Hossain A, Mooney CJ, Parmentier J, Remick SC. Anaplastic thyroid cancer: a review of epidemiology, pathogenesis, and treatment. Journal of oncology. 2011 Oct;2011.\u003c/li\u003e\n\u003cli\u003eZalzal HG, Chung J, Perini JA. Remarkable Presentation: Anaplastic Thyroid Carcinoma Arising from Chronic Hyperthyroidism. Case Reports in Endocrinology. 2018 Apr 1;2018.\u003c/li\u003e\n\u003cli\u003eHaddad RI, Lydiatt WM, Ball DW, Busaidy NL, Byrd D, Callender G, Dickson P, Duh QY, Ehya H, Haymart M, Hoh C. Anaplastic thyroid carcinoma, version 2.2015. Journal of the National Comprehensive Cancer Network. 2015 Sep 1;13(9):1140-50.\u003c/li\u003e\n\u003cli\u003eSobin LH, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumours: John Wiley \u0026amp; Sons; 2011. \u003c/li\u003e\n\u003cli\u003eOnoda N, Sugitani I, Ito KI, Suzuki A, Higashiyama T, Fukumori T, Suganuma N, Masudo K, Nakayama H, Uno A, Yane K. Evaluation of the 8th edition TNM classification for anaplastic thyroid carcinoma. Cancers. 2020 Mar;12(3):552.12(3), p.552. \u003c/li\u003e\n\u003cli\u003eBible KC, Kebebew E, Brierley J, Brito JP, Cabanillas ME, Clark Jr TJ, Di Cristofano A, Foote R, Giordano T, Kasperbauer J, Newbold K. 2021 american thyroid association guidelines for management of patients with anaplastic thyroid cancer: American thyroid association anaplastic thyroid cancer guidelines task force. Thyroid. 2021 Mar 1;31(3):337-86.\u003c/li\u003e\n\u003cli\u003eXia Q, Wang W, Xu J, Chen X, Zhong Z, Sun C. Evidence from an updated meta-analysis of the prognostic impacts of postoperative radiotherapy and chemotherapy in patients with anaplastic thyroid carcinoma. OncoTargets and therapy. 2018;11:2251.\u003c/li\u003e\n\u003cli\u003eKebebew E, Greenspan FS, Clark OH, Woeber KA, McMillan A. Anaplastic thyroid carcinoma: treatment outcome and prognostic factors. Cancer. 2005 Apr 1;103(7):1330-5.\u003c/li\u003e\n\u003cli\u003eLiu TR, Xiao ZW, Xu HN, Long Z, Wei FQ, Zhuang SM, Sun XM, Xie LE, Mu JS, Yang AK, Zhang GP. Treatment and prognosis of anaplastic thyroid carcinoma: a clinical study of 50 cases. PLoS One. 2016 Oct 19;11(10):e0164840.\u003c/li\u003e\n\u003cli\u003eJiang JY, Tseng FY. Prognostic factors of anaplastic thyroid carcinoma. Journal of endocrinological investigation. 2006 Jan;29(1):11-7.\u003c/li\u003e\n\u003cli\u003eGilliland FD, Hunt WC, Morris DM, Key CR. Prognostic factors for thyroid carcinoma: A population‐based study of 15,698 cases from the Surveillance, Epidemiology and End Results (SEER) Program 1973\u0026ndash;1991. Cancer: Interdisciplinary International Journal of the American Cancer Society. 1997 Feb 1;79(3):564-73.\u003c/li\u003e\n\u003cli\u003eAgrawal S, Rao RS, Parikh DM, Parikh HK, Borges AM, Sampat MB. Histologic trends in thyroid cancer 1969\u0026ndash;1993: a clinico‐pathologic analysis of the relative proportion of anaplastic carcinoma of the thyroid. Journal of surgical oncology. 1996 Dec;63(4):251-5.\u003c/li\u003e\n\u003cli\u003eXu Z, Taylor JA. Genome-wide age-related DNA methylation changes in blood and other tissues relate to histone modification, expression and cancer. Carcinogenesis. 2014 Feb 1;35(2):356-64.\u003c/li\u003e\n\u003cli\u003eIto Y, Onoda N, Okamoto T. The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: core questions and recommendations for treatments of thyroid cancer. Endocrine journal. 2020: EJ20-0025.\u003c/li\u003e\n\u003cli\u003eLim SM, Shin SJ, Chung WY, Park CS, Nam KH, Kang SW, Keum KC, Kim JH, Cho JY, Hong YK, Cho BC. Treatment outcome of patients with anaplastic thyroid cancer: a single center experience. Yonsei medical journal. 2012 Mar 1;53(2):352-7. \u003c/li\u003e\n\u003cli\u003eKasemsiri P, Chaisakgreenon P, Vatanasapt P, Laohasiriwong S, Teeramatwanich W, Thongrong C, Ratanaanekchai T, Suetrong S. Survival Benefit of Intervention Treatment in Advanced Anaplastic Thyroid Cancer. International Journal of Surgical Oncology. 2021 Jun 3;2021.\u003c/li\u003e\n\u003cli\u003eMasui T, Uemura H, Ota I, Kimura T, Nishikawa D, Yamanaka T, Yane K, Kitahara T. A study of 17 cases for the identification of prognostic factors for anaplastic thyroid carcinoma. Molecular and Clinical Oncology. 2021 Jan 1;14(1):1-.\u003c/li\u003e\n\u003cli\u003eAkaishi J, Sugino K, Kitagawa W, Nagahama M, Kameyama K, Shimizu K, Ito K, Ito K. Prognostic factors and treatment outcomes of 100 cases of anaplastic thyroid carcinoma. Thyroid. 2011 Nov 1;21(11):1183-9.\u003c/li\u003e\n\u003cli\u003eUs-Krasovec M, Golouh R, Auersperg M, Besic N, Ruparcic-Oblak L. Anaplastic thyroid carcinoma in fine needle aspirates. Acta cytologica. 1996 Sep 1;40(5):953-8.\u003c/li\u003e\n\u003cli\u003eSun C, Li Q, Hu Z, He J, Li C, Li G, Tao X, Yang A. Treatment and prognosis of anaplastic thyroid carcinoma: experience from a single institution in China. PloS one. 2013 Nov 5;8(11):e80011.\u003c/li\u003e\n\u003cli\u003eOliinyk D, Augustin T, Koehler VF, Rauch J, Belka C, Spitzweg C, K\u0026auml;smann L. Hypofractionated radiotherapy for anaplastic thyroid cancer: Systematic review and pooled analysis. Cancers. 2020 Sep;12(9):2506.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anaplastic thyroid carcinoma, surgery, multimodal therapy, prognosis, survival, Kurdistan region Iraq","lastPublishedDoi":"10.21203/rs.3.rs-1687784/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1687784/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Anaplastic thyroid carcinoma is a rare and lethal disease that accounts for 1–2% of thyroid malignancies. It is an aggressive locoregional disease, with a high rate of distant metastasis, a poor prognosis, and a mean survival rate of 3–6\u0026nbsp;months after diagnosis. The aim of this retrospective study is to analyse clinical and pathological features of ATC in order to assess treatment procedures and its outcome. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We analysed data from 22 patients diagnosed with ATC in the period from 2018 to 2021, using the Kaplan-Meier method and log-rank test to determine overall survival. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Patients’ median age was 64.3 ± 17.1 years. Females were more affected (male/female ratio: 1:1.7); 14 cases occurred in females (63.6.4%), and eight in males (36.4%). The most common manifestations were neck enlargement (81.8%) and dyspnoea (72.27%), and the tumour size was \u0026gt; 4cm in 17 (77.3%) patients. The percentage of cases that presented in clinical-stage IVA was 36.4%, with 31.8% presenting in clinical-stage IVB, and 31.8% presenting in clinical-stage VIB. Among 22 cases, 14 (63.6%) were operable, and 8 (36.4) were inoperable (p=0.015). Multimodal therapies were associated with better survival (surgery plus radiotherapy without systemic treatment, \u003cem\u003eP\u003c/em\u003e = 0.063). The median overall survival was three months (IC 95%, 0.078–5.922). One-year and two-year survival rates were 9% and 4.5%, respectively. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e ATC is a rapidly growing cancer that fortunately is rare. Early diagnosis and multimodality treatment may provide a better quality of life and survival time for this group of patients.\u003c/p\u003e","manuscriptTitle":"Evaluation of Anaplastic thyroid carcinoma in the Kurdistan Region of Iraq","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-14 15:58:17","doi":"10.21203/rs.3.rs-1687784/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-07-20T08:08:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-07-13T21:34:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165a7a60-9a30-4e7a-9777-e1ec0507ffcd","date":"2022-07-04T12:32:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-06-19T16:40:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-06-19T16:38:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-06-09T08:58:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-06-09T08:55:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2022-05-24T08:32:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f5da613b-2039-4a5a-a0f0-39f82cf97b3e","owner":[],"postedDate":"June 14th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-09-29T09:59:33+00:00","versionOfRecord":[],"versionCreatedAt":"2022-06-14 15:58:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1687784","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1687784","identity":"rs-1687784","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}