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Ito Y, Miyauchi A, Oda H, Masuoka H, Higashiyama T, Kihara M, Miya A. Appropriateness of the revised Japanese guidelines' risk classification for the prognosis of papillary thyroid carcinoma: a retrospective analysis of 5,845 papillary thyroid carcinoma patients. Endocr J 2019; 66:127-134. [PMID: 30626761 DOI: 10.1507/endocrj.ej17-0061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The revised Japan Association of Endocrine Surgeons (JAES)/Japanese Society of Thyroid Surgery (JSTS) guidelines for patients with papillary thyroid carcinoma (PTC) describe four risk classes: very-low-risk, low-risk, intermediate-risk, and high-risk. Here we conducted a retrospective analysis to evaluate the appropriateness of these guidelines' risk classification of PTCs. Lymph node recurrence-free, distant recurrence-free and cause-specific survivals at 15-year of high-risk group were significantly poorer than those at 15-year of intermediate-group and these survivals of intermediate-group were poorer than of low- or very-low-risk patients. In the subset analyses based on patient age (≥55 years and <55 years), we obtained the same results in both subsets. Age significantly worsen the whole prognosis of high-risk patients and cause-specific survival of intermediate-risk patients, but not the prognosis of low- or very-low-risk patients. Therefore, the risk classification of the revised JAES/JSTS guidelines is appropriate, and therapeutic strategies should be decided based on the risk class together with the patients' age.
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Hyogo Y, Kiyota N, Otsuki N, Goto S, Imamura Y, Chayahara N, Toyoda M, Nibu KI, Hyodo T, Hara S, Masuoka H, Kasahara T, Ito Y, Miya A, Hirokawa M, Miyauchi A, Minami H. Thrombotic Microangiopathy with Severe Proteinuria Induced by Lenvatinib for Radioactive Iodine-Refractory Papillary Thyroid Carcinoma. Case Rep Oncol 2018; 11:735-741. [PMID: 30519176 PMCID: PMC6276762 DOI: 10.1159/000494080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022] Open
Abstract
Standard therapy for radioactive iodine (RAI)-refractory differentiated thyroid cancer (DTC) is multi-targeted kinase inhibitors (m-TKIs), represented by sorafenib and lenvatinib. One of the main target molecules of m-TKIs is vascular endothelial growth factor receptor (VEGF-R). m-TKIs are known to cause adverse reactions such as hypertension and proteinuria as a class effect. In particular, proteinuria is thought to result from vascular endothelial damage and podocytopathy in glomeruli, and the development of thrombotic microangiopathy (TMA) has been reported for VEGF inhibitors. We encountered a patient with RAI-refractory (RR) papillary thyroid carcinoma (PTC) who developed proteinuria and renal dysfunction due to lenvatinib. Renal biopsy demonstrated that these changes were caused by TMA. To our knowledge, this is the first reported case of TMA due to lenvatinib in a Japanese patient with RR-PTC. A 70-year-old woman developed proteinuria, renal impairment and hypertension while receiving lenvatinib for RR-PTC. Her proteinuria and renal damage continued to worsen despite dose reductions and dose interruptions. Renal biopsy was consistent with the chronic type of TMA. These findings indicate that TMA is a possible cause of proteinuria due to lenvatinib, as has been reported for the VEGF inhibitors.
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Miyauchi A, Kudo T, Ito Y, Oda H, Yamamoto M, Sasai H, Higashiyama T, Masuoka H, Fukushima M, Kihara M, Miya A. Natural history of papillary thyroid microcarcinoma: Kinetic analyses on tumor volume during active surveillance and before presentation. Surgery 2018; 165:25-30. [PMID: 30413323 DOI: 10.1016/j.surg.2018.07.045] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 06/18/2018] [Accepted: 07/05/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND We report on the growth of papillary microcarcinoma during active surveillance and before clinical presentation. METHODS We conducted a retrospective study of 169 patients with papillary microcarcinoma who were enrolled in active surveillance at our hospital between 2000 and 2004. Patients were followed for a median of 10.1 years using serial ultrasonography (median, 12 examinations), used to calculate the tumor doubling time. To contextualize tumor growth rates during active surveillance, we calculated the hypothetical tumor doubling time before clinical presentation. To resolve the limitations in tumor doubling time, tumor doubling rates were inversely transformed into doubling rates. RESULTS The doubling rates (per year) during active surveillance (median: 0.0) were >0.5, 0.1 to 0.5, -0.1 to 0.1, and <-0.1 in 5, 38, 97, and 29 cases, respectively. The proportions of tumors with rather rapid growth, slow growth, stable, and a decrease in size were 3%, 22%, 57%, and 17%, respectively. CONCLUSION Tumor growth of papillary microcarcinomas varies from rather rapid growth to a decrease in size during active surveillance.
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Kihara M, Hirokawa M, Kudo T, Hayashi T, Yamamoto M, Masuoka H, Higashiyama T, Fukushima M, Ito Y, Miya A, Miyauchi A. Calcitonin measurement in fine-needle aspirate washout fluid by electrochemiluminescence immunoassay for thyroid tumors. Thyroid Res 2018; 11:15. [PMID: 30450128 PMCID: PMC6208047 DOI: 10.1186/s13044-018-0059-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/17/2018] [Indexed: 12/17/2022] Open
Abstract
Purpose For the differential diagnosis of medullary thyroid carcinoma (MTC) on thyroid nodules, ultrasound-guided fine-needle aspiration cytology is a useful and safe procedure, but its diagnostic accuracy is not high enough. As an ancillary method to accurately diagnose MTC, the calcitonin in fine-needle aspirate washout fluid (FNA-Ct) is used. However, no data are available about cut-off values of FNA-Ct using the currently available electrochemiluminescence immunoassay (ECLIA). Methods We investigated 180 thyroid nodules in 141 patients. After smearing, the syringe and needle used for the FNA were rinsed with normal saline (0.5 mL). The calcitonin in the washout was measured by ECLIA. Results The FNA-Ct in the non-MTC nodules of MTC patients, non-MTC nodules of non-MTC patients, and MTC nodules were 10.6-2100 pg/mL (median 24.6 pg/mL), < 0.5-21.0 pg/mL (median < 0.5 pg/mL), and 94.9-4,070,000 pg/mL (median 177,000 pg/mL), respectively. A receiver operating characteristic analysis of the MTC nodules and the non-MTC nodules of the non-MTC patients indicated that the cut-off value was 21.0 pg/mL, leading to 100% sensitivity and 100% specificity. Conclusions This is the first study to determine the cut-off value of FNA-Ct with an ECLIA, and we propose that the optimal cut-off value is 21.0 pg/mL.
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Ito Y, Miyauchi A, Masuoka H, Fukushima M, Kihara M, Miya A. Excellent Prognosis of Central Lymph Node Recurrence-Free Survival for cN0M0 Papillary Thyroid Carcinoma Patients Who Underwent Routine Prophylactic Central Node Dissection. World J Surg 2018; 42:2462-2468. [PMID: 29372373 PMCID: PMC6060821 DOI: 10.1007/s00268-018-4497-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction In Japan, prophylactic central node dissection (p-CND) for papillary thyroid carcinoma (PTC) has been routinely performed in many institutions, including ours (Kuma Hospital, Japan). We evaluated the recurrence to a central lymph node in patients with cN0M0 PTC who underwent routine p-CND. Materials and methods We enrolled 4301 patients with cN0M0 PTC who underwent an initial surgery between 1987 and 2005 (median age 51 years). The postoperative follow-up periods ranged from 4 to 362 months (median 164 months). Only 15 patients underwent radioactive iodine (RAI) ablation (≥30 mCi) after total or near total thyroidectomy. Results Of the 4301 patients with N0M0 PTC who underwent p-CND, 2548 (59%) were diagnosed as pN1a on postoperative pathological examination. To date, only 52 cases (1.2%) showed recurrence to a central lymph node. The 10-year and 20-year central node recurrence-free survival rates were excellent at 99.1 and 98.2%, respectively. On multivariate analysis, age ≥55 years, significant extrathyroid extension, tumor size >2 cm, and ≥5 pathologically confirmed central node metastases (but not the presence of central node metastasis) independently affected central node recurrence. Conclusions Under the situation of routine p-CND, the central node recurrence-free survival of cN0M0 PTC is excellent. However, future studies, including double-arm studies from Japan, should examine whether the omission of p-CND cN0M0 PTC is appropriate without RAI ablation in consideration of various factors, including the pros and cons of p-CND.
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Ito Y, Miyauchi A, Hirokawa M, Yamamoto M, Oda H, Masuoka H, Sasai H, Fukushima M, Higashiyama T, Kihara M, Miya A. Prognostic value of the 8 th edition of the tumor-node-metastasis classification for patients with papillary thyroid carcinoma: a single-institution study at a high-volume center in Japan. Endocr J 2018; 65:707-716. [PMID: 29681581 DOI: 10.1507/endocrj.ej18-0019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The tumor-node-metastasis (TNM) staging system is most commonly adopted to evaluate the prognosis of patients with thyroid carcinoma. The 8th edition of the TNM staging system, an extensively revised version of the 7th edition, was recently released. We aimed to investigate whether and how well the 8th edition reflects the cause-specific survival (CSS) of patients with papillary thyroid carcinoma by analyzing the cases in 5,892 patients who underwent initial surgery at Kuma Hospital between 1987 and 2005. The median postoperative follow-up duration was 178 months (range: 6-357 months). One patient with T4b disease was excluded from the analysis. Overall, 116 (2.0%) patients died of thyroid carcinoma. The proportion of variance explained (PVE) for CSS in the 7th and 8th editions was 10.69 and 10.97, respectively. Using the 7th edition, CSS of patients with stage IVA and stage III disease was similar (p = 0.32). In contrast, using the 8th edition, CSS was poorer in stage II than in stage I (p < 0.001), in stage III than in stage II (p < 0.001), and in stage IVB than in stage III (p < 0.001). Similar results were observed for disease-free survival. Although we could not establish any objective evidence that the 8th edition is superior to the 7th edition, the 8th edition is simpler and more convenient, as it includes fewer stages and addresses the issue of the 7th edition where stage IVA and III patients had similar prognoses.
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Ito Y, Miyauchi A, Hirokawa M, Yamamoto M, Oda H, Masuoka H, Sasai H, Fukushima M, Higashiyama T, Kihara M, Miya A. Prognostic value of the 8 th tumor-node-metastasis classification for follicular carcinoma and poorly differentiated carcinoma of the thyroid in Japan. Endocr J 2018; 65:621-627. [PMID: 29618671 DOI: 10.1507/endocrj.ej17-0524] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Follicular thyroid carcinoma (FTC), a form of differentiated thyroid carcinoma, is the second most common malignancy arising from thyroid follicular cells. Recently, the tumor-node-metastasis (TNM) classification for differentiated thyroid carcinoma was revised from the 7th to the 8th edition. The diagnostic criteria for poorly differentiated carcinoma (PDC) were also updated in the latest World Health Organization (WHO) classification. In this study, we investigated whether these changes are appropriate for accurately predicting prognosis. Three hundred and twenty-nine patients diagnosed with postoperative pathologically confirmed FTC, who underwent initial surgery at our hospital between 1984 and 2004, were enrolled. For this study, patients were re-evaluated and diagnosed with FTC (N = 285) or PDC (N = 44) without typical nuclear findings of papillary thyroid carcinoma. For FTC, the 8th TNM classification was a more accurate predictor of prognosis than the 7th TNM classification. In the 8th TNM classification, cause-specific survival became significantly poorer from Stage I to IVB. The cause-specific survival of PDC based on the latest WHO classification was worse than, but did not significantly differ from, that of PDC based only on the former WHO classification. For PDC, neither of the TNM classifications could accurately predict prognosis. Taken together, we conclude that (1) the 8th TNM classification more accurately reflects the prognosis of FTC than the 7th TNM classification; (2) PDC based on the former WHO classification should be retained, at least in Japan; and (3) the TNM classification may not be suitable for predicting the prognosis of PDC.
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Kobayashi K, Fujimoto T, Ota H, Hirokawa M, Yabuta T, Masuoka H, Fukushima M, Higashiyama T, Kihara M, Ito Y, Miya A, Miyauchi A. Calcifications in Thyroid Tumors on Ultrasonography: Calcification Types and Relationship with Histopathological Type. Ultrasound Int Open 2018; 4:E45-E51. [PMID: 30250940 PMCID: PMC6148317 DOI: 10.1055/a-0591-6070] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/19/2018] [Accepted: 03/05/2018] [Indexed: 12/29/2022] Open
Abstract
PURPOSE The purpose of the study is to clarify the prevalence of calcifications within thyroid tumors on ultrasonography as well as the relationship between the calcification and histopathological types. MATERIALS AND METHODS Calcifications were classified into 6 (or 8) types according to their shape, size, and region. The prevalence of calcifications and types were investigated in new outpatients and patients who underwent thyroid surgery. RESULTS Among 2,902 nodules in 2,678 new outpatients, 747 nodules (26%) had calcifications. The types showed a wide distribution. Among 941 patients with papillary carcinoma (PC), 725 patients (77%) had calcifications, and the types showed a wide distribution. 18 patients with the diffuse sclerosing variant of PC only showed punctate microcalcifications in the parenchyma (100%), 32 patients with the cyst-forming type of PC mostly fragmentary and massive types (100%), and 161 metastatic lymph nodes from PC mostly punctate microcalcifications and fragmentary types (48%). Among 337 patients with follicular carcinoma, 79 patients (23%) had calcifications, and the types were mostly fragmentary, massive, and egg-shell types. Among 41 patients with undifferentiated carcinoma, 33 patients (80%) presented with calcifications, which were mostly the massive and egg-shell types. Among 137 patients with medullary carcinoma, 99 patients (72%) had calcification, and the types showed a wide distribution. None of 173 patients with primary thyroid lymphoma had calcifications (0%). CONCLUSION Calcifications on ultrasonography can be one of the characteristic findings and a full understanding of the prevalence of calcifications and types will markedly contribute to the ultrasonic diagnosis of thyroid tumors.
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Ito Y, Miyauchi A, Kudo T, Oda H, Yamamoto M, Sasai H, Masuoka H, Fukushima M, Higashiyama T, Kihara M, Miya A. Trends in the Implementation of Active Surveillance for Low-Risk Papillary Thyroid Microcarcinomas at Kuma Hospital: Gradual Increase and Heterogeneity in the Acceptance of This New Management Option. Thyroid 2018; 28:488-495. [PMID: 29608416 PMCID: PMC5905421 DOI: 10.1089/thy.2017.0448] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Active surveillance (AS) of low-risk papillary thyroid microcarcinoma (PMC) was adopted as a management modality in both the Japanese guidelines in 2011 and the American Thyroid Association guidelines in 2015. AS was initiated at Kuma Hospital in 1993 but was not immediately accepted by all physicians. This study investigated the history of acceptance of AS at Kuma Hospital over time. The results should assist in the implementation of AS at other hospitals in Japan and other countries. METHODS This study included 4023 patients who were cytologically diagnosed with low-risk PMC at Kuma Hospital during the 24-year period between October 1993 and June 2016. The trend in the frequency of AS use over time was analyzed, dividing the 24-year study period into five parts based on the change in frequency of AS use: 1993-1997, 1998-2002, 2003-2006, 2007-2013, and 2014-2016. RESULTS The frequency of AS use in the present cohort was 65%. The frequency gradually increased from 30% in 1993-1997 to 88% in 2014-2016, with a slight decrease from 51% in 1998-2002 to 42% in 2003-2006. Until 2007, patients were mostly seen by surgeons, and the frequency of AS use varied remarkably among individual surgeons. Since 2007, the number of patients whose therapeutic strategies are determined by endocrinologists has increased, and the frequency of AS use for low-risk PMC by endocrinologists has been higher than that by surgeons. CONCLUSIONS At Kuma Hospital, acceptance of AS for low-risk PMC gradually increased over the 24-year study period, but AS was not equally accepted by all physicians. Such variations in the acceptance of AS among individual physicians are also expected to exist in other hospitals. However, due to increasing evidence of the safety and superiority of AS over immediate surgery for this indolent disease, it is expected that AS will gain faster acceptance in other hospitals in Japan and around the world.
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Miyauchi A, Kudo T, Ito Y, Oda H, Sasai H, Higashiyama T, Fukushima M, Masuoka H, Kihara M, Miya A. Estimation of the lifetime probability of disease progression of papillary microcarcinoma of the thyroid during active surveillance. Surgery 2017; 163:48-52. [PMID: 29103582 DOI: 10.1016/j.surg.2017.03.028] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/10/2017] [Accepted: 03/21/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND We reported that a minority of patients with low-risk papillary microcarcinoma of the thyroid showed disease progression during active surveillance and that older patients had significantly lower disease progression rates than younger patients. Here, we estimated lifetime (≤85 years old) probabilities of disease progression during active surveillance according to the age at presentation based on age decade-specific disease progression rates. METHODS From 1993-2013, 1,211 low-risk papillary microcarcinoma patients aged 20-79 years underwent active surveillance at Kuma Hospital. We calculated the disease progression rate at the 10-year point of active surveillance for each age-decade group (20s to 70s) with the Kaplan-Meier method. The lifetime disease progression probability for each age group was calculated as (1 - cumulative probability of progression-free survival calculated with age decade-specific disease progression rates) until the patients reached their 80s (i.e., 85 years on average). RESULTS The age decade-specific disease progression rates at 10 years of active surveillance were 36.9% (20s), 13.5% (30s), 14.5% (40s), 5.6% (50s), 6.6% (60s), and 3.5% (70s); the respective lifetime disease progression probabilities were 60.3%, 37.1%, 27.3%, 14.9%, 9.9% and 3.5% according to the age at presentation. CONCLUSION The estimated lifetime disease progression probabilities of papillary microcarcinoma during active surveillance vary greatly according to the age at presentation.
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Kobayashi K, Ota H, Hirokawa M, Yabuta T, Fukushima M, Masuoka H, Higashiyama T, Kihara M, Ito Y, Miya A, Miyauchi A. "Nodule in Nodule" on Thyroid Ultrasonography: Possibility of Follicular Carcinoma Transformed from Benign Thyroid Tumor. Eur Thyroid J 2017; 6:101-107. [PMID: 28589092 PMCID: PMC5422757 DOI: 10.1159/000452971] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/31/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND It is generally considered impossible to differentiate follicular carcinomas from follicular adenomas by means of ultrasonography or cytology before surgery. Therefore, follicular carcinoma is histopathologically diagnosed by verifying capsular and/or vascular invasion after surgery. However, ultrasonography may play an important role in diagnosing follicular carcinoma preoperatively in a small number of cases. CASE DESCRIPTION Four cases of follicular carcinoma or follicular neoplasm that transformed from a benign thyroid tumor and demonstrated a "nodule in nodule" appearance on ultrasonography are presented in this report. Characteristic ultrasound features of such patients are: (1) a "nodule in nodule" appearance, (2) a well-defined boundary line between the nodules, and (3) separate distribution of blood signals within each nodule. CONCLUSION A small number of patients with follicular carcinomas or follicular neoplasms may present with a "nodule in nodule" appearance on ultrasonography. It was suggested a long time ago that follicular carcinomas may develop from benign thyroid tumors. The fact that follicular carcinomas appear within benign tumors may be evidence of thyroid tumorigenesis.
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Oda H, Miyauchi A, Ito Y, Sasai H, Masuoka H, Yabuta T, Fukushima M, Higashiyama T, Kihara M, Kobayashi K, Miya A. Comparison of the costs of active surveillance and immediate surgery in the management of low-risk papillary microcarcinoma of the thyroid. Endocr J 2017; 64:59-64. [PMID: 27667647 DOI: 10.1507/endocrj.ej16-0381] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The incidence of thyroid cancer is increasing rapidly in many countries, resulting in rising societal costs of the care of thyroid cancer. We reported that the active surveillance of low-risk papillary microcarcinoma had less unfavorable events than immediate surgery, while the oncological outcomes of these managements were similarly excellent. Here we calculated the medical costs of these two managements. We created a model of the flow of these managements, based on our previous study. The flow and costs include the step of diagnosis, surgery, prescription of medicine, recurrence, salvage surgery for recurrence, and care for 10 years after the diagnosis. The costs were calculated according to the typical clinical practices at Kuma Hospital performed under the Japanese Health Care Insurance System. If conversion surgeries were not considered, the 'simple cost' of active surveillance for 10 years was 167,780 yen/patient. If there were no recurrences, the 'simple cost' of immediate surgery was calculated as 794,770 yen/patient to 1,086,070 yen/patient, depending on the type of surgery and postoperative medication. The 'simple cost' of surgery was 4.7 to 6.5 times the 'simple cost' of surveillance. When conversion surgeries and recurrence were considered, the 'total cost' of active surveillance for 10 years became 225,695 yen/patient. When recurrence were considered, the 'total cost' of immediate surgery was 928,094 yen/patient, which was 4.1 times the 'total cost' of the active surveillance. At Kuma Hospital in Japan, the 10-year total cost of immediate surgery was 4.1 times expensive than active surveillance.
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Iwaki S, Maeda T, Saito M, Otsuki N, Takahashi M, Wakui E, Shinomiya H, Morimoto K, Inoue H, Masuoka H, Miyauchi A, Nibu K. Role of immediate recurrent laryngeal nerve reconstruction in surgery for thyroid cancers with fixed vocal cords. Head Neck 2016; 39:427-431. [DOI: 10.1002/hed.24627] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 07/18/2016] [Accepted: 10/07/2016] [Indexed: 11/12/2022] Open
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Ito Y, Hirokawa M, Miyauchi A, Kihara M, Yabuta T, Masuoka H, Fukushima M, Higashiyama T, Kobayashi K, Miya A. Diagnosis and surgical indications of oxyphilic follicular tumors in Japan: Surgical specimens and cytology. Endocr J 2016; 63:977-982. [PMID: 27465606 DOI: 10.1507/endocrj.ej16-0268] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Oxyphilic cell carcinoma is a relatively rare type of differentiated thyroid carcinoma. We investigated the diagnosis of oxyphilic cell carcinoma based on surgical specimens and cytology to elucidate the indications for surgery for oxyphilic tumors. Among 330 patients pathologically diagnosed as having an oxyphilic cell carcinoma or adenoma, the incidence of carcinoma was 21%. The pathological diagnosis of oxyphilic cell carcinoma was related to tumor size (>4 cm). On cytology, 79% of the tumors were classified as category IV or greater by the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), but no significant difference was established between category IV or greater and categories I-III regarding the incidence of carcinoma. Of 998 patients cytologically diagnosed as having oxyphilic cell tumors (BSRTC category IV), 426 underwent surgery and 66 (15%) were diagnosed as malignancies. In a univariate analysis, serum thyroglobulin (Tg) levels (>500 ng/dL) for anti-Tg antibody-negative patients, tumor size (>4 cm) and US class (≥3) significantly predicted malignant histology. A multivariate logistic analysis revealed that US finding was an independent predictor of malignant histology, and tumor size (>4 cm) also predicted malignancy when the Tg level was excluded from the variables. These findings suggest that, for thyroid tumors diagnosed as oxyphilic follicular neoplasms on cytology, surgical indications are tumors with US class ≥3, tumor size >4 cm, and Tg >500 ng/dL (with negative Tg-antibody). It is not appropriate to perform surgery for all cases for a precise histological classification, unlike the BSRTC recommendation.
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Ito Y, Hirokawa M, Miyauchi A, Masuoka H, Yabuta T, Fukushima M, Kihara M, Higashiyama T, Kobayashi K, Miya A. Prognostic impact of Ki-67 labeling index in minimally invasive follicular thyroid carcinoma. Endocr J 2016; 63:913-917. [PMID: 27432822 DOI: 10.1507/endocrj.ej16-0277] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We investigated the prognostic impact of the Ki-67 labeling index (LI) in minimally invasive follicular thyroid carcinoma (FTC). We enrolled 192 patients (including four with distant metastasis at diagnosis) who were pathologically diagnosed as having minimally invasive FTC between 1998 and 2007 at Kuma Hospital. When the Ki-67 LI was higher than 5% in the hot area, we regarded it as a high Ki-67 LI. In a univariate analysis, patient age (≥45 years), high-frequent vascular invasion (≥4 in H&E specimens), and high Ki-67 LI significantly predicted the disease-free survival (DFS) of the patients. Since none of the patients <45 years old showed a recurrence, we performed a multivariate analysis of variables other than patient age. In the multivariate analysis including the presence of vascular invasion, high Ki-67 LI was an independent predictor of carcinoma recurrence. However, in the multivariate analysis including high-frequent vascular invasion, only high-frequent vascular invasion independently affected the DFS. These findings suggest that the Ki-67 LI has a rather strong prognostic value for the DFS of patients, although its impact was less than those of patient age and high-frequent vascular invasion.
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Kihara M, Miyauchi A, Yoshioka K, Oda H, Nakayama A, Sasai H, Yabuta T, Masuoka H, Higashiyama T, Fukushima M, Ito Y, Kobayashi K, Miya A. Germline RET mutation carriers in Japanese patients with apparently sporadic medullary thyroid carcinoma: A single institution experience. Auris Nasus Larynx 2016; 43:551-5. [DOI: 10.1016/j.anl.2015.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/10/2015] [Accepted: 12/23/2015] [Indexed: 01/08/2023]
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Suzuki A, Hirokawa M, Takada N, Masuoka H, Miyauchi A. Thyroid follicular adenoma with numerous intracytoplasmic lumina mimicking yellow bodies: a case report. Cytopathology 2016; 27:495-498. [PMID: 27146719 DOI: 10.1111/cyt.12339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2016] [Indexed: 11/30/2022]
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Masuoka H, Miyauchi A, Higashiyama T, Yabuta T, Kihara M, Miya A. Right-sided aortic arch and aberrant left subclavian artery with or without a left nonrecurrent inferior laryngeal nerve. Head Neck 2016; 38:E2508-11. [PMID: 27131222 PMCID: PMC5074330 DOI: 10.1002/hed.24492] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/22/2016] [Accepted: 03/22/2016] [Indexed: 11/23/2022] Open
Abstract
Background In thyroid surgery, preserving the recurrent laryngeal nerve (RLN) is crucial for preventing postoperative phonatory dysfunction. Right nonrecurrent laryngeal nerves (NRLNs) are not particularly rare, and they are vulnerable to injury during surgery. This anomaly is associated with a right aberrant subclavian artery. Thus, a right‐sided aortic arch with an aberrant left subclavian artery (LSA) suggests a possible left NRLN. Methods We report the cases of 4 patients with right‐sided aortic arch and aberrant LSA. Preoperative imaging studies revealed those anomalies, but no signs of situs inversus. During the surgeries, only 1 of the 4 cases had a left NRLN. We retrospectively evaluated the patients' imaging studies. Results An aortic diverticulum was found at the point at which the aberrant LSA originated in the 3 patients with left‐RLNs, but not in the patient with the left‐NRLN. Conclusion In right‐sided aortic arch + aberrant LSA cases, the absence of an aortic diverticulum suggests a left NRLN. © 2016 Wiley Periodicals, Inc. Head Neck 38: First–E2511, 2016
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Kobayashi K, Hirokawa M, Yabuta T, Masuoka H, Fukushima M, Kihara M, Higashiyama T, Ito Y, Miya A, Amino N, Miyauchi A. Tumor protrusion with intensive blood signals on ultrasonography is a strongly suggestive finding of follicular thyroid carcinoma. MEDICAL ULTRASONOGRAPHY 2016; 18:25-29. [PMID: 26962550 DOI: 10.11152/mu.2013.2066.181.kok] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
AIM It is difficult to differentiate follicular carcinomas (FC) from follicular adenomas (FA) because ultrasonography and cytology provide very similar findings. FC is histopathologically diagnosed to have capsular and/or vascular invasion. In a few patients, tumor protrusions are observed by preoperative ultrasonography as large forms of capsular invasion of follicular carcinomas. The aim of the study was to clarify the predictive value of tumor protrusions on preoperative ultrasonography for follicular carcinomas. MATERIAL AND METHODS A total of 531 patients (FC: 184 patients, FA: 347 patients) undergoing thyroid surgery were included in this study. A tumor protrusion on ultrasonography was defined as follows: 1) a solid tumor extending beyond a marginal line of capsular zone of the main tumor on B-mode ultrasonography; 2) intensive blood signals observed within the protrusion area on Doppler ultrasonography. The large form of capsular invasion was defined if the protrusion lesion was histopathologically diagnosed to be a capsular invasion of follicular carcinoma. RESULTS The sensitivity of tumor protrusion was 0.071, specificity 0.994, positive predictive value 0.867, and negative predictive value 0.669 for FC diagnosis. For the large form of capsular invasion in FC the sensitivity of tumor protrusion was 0.813, specificity 0.982, positive predictive value 0.684, and negative predictive value 0.982. CONCLUSIONS A tumor protrusion with intensive blood signals extending from the main tumor on ultrasonography strongly suggests a large form of capsular invasion of follicular carcinoma.
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Niikura N, Tomotaki A, Miyata H, Iwamoto T, Kawai M, Anan K, Hayashi N, Aogi K, Ishida T, Masuoka H, Iijima K, Masuda S, Tsugawa K, Kinoshita T, Nakamura S, Tokuda Y. Changes in tumor expression of HER2 and hormone receptors status after neoadjuvant chemotherapy in 21 755 patients from the Japanese breast cancer registry. Ann Oncol 2016; 27:480-7. [DOI: 10.1093/annonc/mdv611] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/28/2015] [Indexed: 12/17/2022] Open
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Oda H, Miyauchi A, Ito Y, Yoshioka K, Nakayama A, Sasai H, Masuoka H, Yabuta T, Fukushima M, Higashiyama T, Kihara M, Kobayashi K, Miya A. Incidences of Unfavorable Events in the Management of Low-Risk Papillary Microcarcinoma of the Thyroid by Active Surveillance Versus Immediate Surgery. Thyroid 2016; 26:150-5. [PMID: 26426735 PMCID: PMC4739129 DOI: 10.1089/thy.2015.0313] [Citation(s) in RCA: 222] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The incidence of papillary microcarcinoma (PMC) of the thyroid is rapidly increasing globally, making the management of PMC an important clinical issue. Excellent oncological outcomes of active surveillance for low-risk PMC have been reported previously. Here, unfavorable events following active surveillance and surgical treatment for PMC were studied. METHODS From February 2005 to August 2013, 2153 patients were diagnosed with low-risk PMC. Of these, 1179 patients chose active surveillance and 974 patients chose immediate surgery. The oncological outcomes and the incidences of unfavorable events of these groups were analyzed. RESULTS In the active surveillance group, 94 patients underwent surgery for various reasons; tumor enlargement and the appearance of novel lymph node metastases were the reasons in 27 (2.3%) and six patients (0.5%), respectively. One of the patients with conversion to surgery had nodal recurrence, and five patients in the immediate surgery group had a recurrence in a cervical node or unresected thyroid lobe. All of these recurrences were successfully treated. None of the patients had distant metastases, and none died of the disease. The immediate surgery group had significantly higher incidences of transient vocal cord paralysis (VCP), transient hypoparathyroidism, and permanent hypoparathyroidism than the active-surveillance group did (4.1% vs. 0.6%, p < 0.0001; 16.7% vs. 2.8%, p < 0.0001; and 1.6% vs. 0.08%, p < 0.0001, respectively). Permanent VCP occurred only in two patients (0.2%) in the immediate surgery group. The proportion of patients on L-thyroxine for supplemental or thyrotropin (TSH)-suppressive purposes was significantly larger in the immediate surgery group than in the active surveillance group (66.1% vs. 20.7%, p < 0.0001). The immediate surgery group had significantly higher incidences of postsurgical hematoma and surgical scar in the neck compared with the active surveillance group (0.5% vs. 0%, p < 0.05; and 8.0% vs. 100%, p < 0.0001, respectively). CONCLUSIONS The oncological outcomes of the immediate surgery and active surveillance groups were similarly excellent, but the incidences of unfavorable events were definitely higher in the immediate surgery group. Thus, active surveillance is now recommended as the best choice for patients with low-risk PMC.
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Ito Y, Miyauchi A, Kudo T, Ota H, Yoshioka K, Oda H, Sasai H, Nakayama A, Yabuta T, Masuoka H, Fukushima M, Higashiyama T, Kihara M, Kobayashi K, Miya A. Effects of Pregnancy on Papillary Microcarcinomas of the Thyroid Re-Evaluated in the Entire Patient Series at Kuma Hospital. Thyroid 2016; 26:156-60. [PMID: 26670937 PMCID: PMC4739387 DOI: 10.1089/thy.2015.0393] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND An active-surveillance clinical trial of low-risk papillary microcarcinoma (PMC) patients has been performed at the authors' institution, Kuma Hospital, since 1993. Favorable oncological results have been reported. During the trial, a few patients were encountered with PMC that showed enlargement during pregnancy, and these cases have been reported. During pregnancy, a large amount of human chorionic gonadotropin (hCG) having weak thyrotropin (TSH) activity is produced, possibly affecting the progression of PMC. This study investigated how pregnancy and delivery influenced the progression of PMC in the entire active surveillance PMC patient series. METHODS From 1993 to 2013, 1841 patients with low-risk PMC chose the active surveillance program. Fifty of the 1549 female PMC patients experienced 51 pregnancies/deliveries. To minimize observer variation, a single specialist sonographer re-evaluated the changes in the size of these 50 patients' PMCs before and after the pregnancies/deliveries. RESULTS Four patients (8%) showed enlargement of PMC by ≥3 mm; one patient (2%) showed a decrease by ≥3 mm, and the remaining 44 patients (45 events, 90%) showed stable disease. None of the patients had a novel appearance of lymph node metastases during pregnancy. Of the four patients with enlargement, two underwent surgery after delivery, and the other two continued the active surveillance, since their tumors did not grow after the delivery. After delivery, the PMC of one of these four patients remained stable, and another showed a decrease in PMC size. To date, six more PMC patients underwent surgery after delivery for reasons other than disease progression due to pregnancy and delivery: two opted out of active surveillance, two were identified with a nodal metastasis during active surveillance after delivery, one had Graves' disease, and one showed enlargement of nodules of the contralateral lobe. CONCLUSIONS Pregnancy and delivery was associated with an increase in size of PMCs in only 8% of the 51 pregnancies/delivery cases. None of the patients developed nodal metastasis during pregnancy. Thus, a possible future pregnancy does not prevent such patients from undergoing active surveillance, although watchful observation during pregnancy is recommended.
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Miyauchi A, Masuoka H, Nakayama A, Higashiyama T. Innervation of the cricothyroid muscle by extralaryngeal branches of the recurrent laryngeal nerve. Laryngoscope 2015; 126:1157-62. [PMID: 26509739 PMCID: PMC5061096 DOI: 10.1002/lary.25691] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/21/2015] [Accepted: 08/27/2015] [Indexed: 11/27/2022]
Abstract
Objectives/Hypothesis A major concern in thyroid surgery is possible changes in the patient's voice due to dysfunction of the laryngeal muscles. The classical understanding of the anatomy is that the cricothyroid muscle (CTM) is innervated solely by the external branch of the superior laryngeal nerve (EBSLN), and the endolaryngeal muscles are covered only by the recurrent laryngeal nerve (RLN). Meticulous anatomical studies found communication between these nerves. Recent neurophysiological studies revealed cross‐innervations among these nerve–muscle sets. Here, we report innervation of the CTM by extralaryngeal branches of the RLN. Study Design Clinical observation during thyroid surgery at a hospital center for thyroid diseases. Methods During thyroid cancer surgeries, we encountered four adult Japanese patients who had an extralaryngeal branch of the RLN, the electrical stimulation of which showed contraction of the CTM. The EBSLN and RLN were electrically stimulated. Responses were evaluated by visual observation of contraction of the CTM and palpable laryngeal twitch of the endolaryngeal muscles. Electromyographic studies were also performed in two patients. Results Five of the seven RLNs examined showed contraction of the CTM on stimulation. Four of these five RLNs had an extralaryngeal branch that showed contraction of the CTM on stimulation. Stimulation of the RLN proximal to the branch yielded contraction of the CTM and laryngeal twitch, whereas stimulation of the RLN distal to the branch yielded only laryngeal twitch. Conclusions Extralaryngeal branches of the RLN innervated the CTM in four patients. This phenomenon might influence voice changes following thyroid surgery. Level of Evidence 4. Laryngoscope, 126:1157–1162, 2016
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Kim HY, Tufano RP, Randolph G, Barczyński M, Wu CW, Chiang FY, Liu X, Masuoka H, Miyauchi A, Park SY, Kwak HY, Lee HY, Dionigi G. Impact of positional changes in neural monitoring endotracheal tube on amplitude and latency of electromyographic response in monitored thyroid surgery: Results from the Porcine Experiment. Head Neck 2015; 38 Suppl 1:E1004-8. [PMID: 26040955 DOI: 10.1002/hed.24145] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/14/2015] [Accepted: 05/31/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate electromyography (EMG) amplitude and latency changes during tube dislocation in monitored thyroid surgery, which may be observed without recurrent laryngeal nerve injury. METHODS Duroc-Landrace piglets were intubated with the TriVantage EMG tube. We measured EMG changes during both upward and downward tube dislocation (10-20 mm) and rotation (45-90°) with continuous neuromonitoring. RESULTS The EMG amplitude varied significantly with induced endotracheal tube rotation and depth changes. However, the EMG latency was relatively unaffected by such tube dislocation, just a transient artifactual latency change was observed in the situation of extreme amplitude variation. CONCLUSION Amplitude changes without latency changes may be due to changes in tube position alone during surgery, but could still reflect a neurophysiologic event; amplitude changes during neuropraxic injury merit additional investigation. Thus, the combined event (concordant amplitude decrease and latency increase) serves as an appropriate adverse EMG event correlating with impending neural injury. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1004-E1008, 2016.
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Masuoka H, Miyauchi A, Yabuta T, Fukushima M, Miya A. Innervation of the cricothyroid muscle by the recurrent laryngeal nerve. Head Neck 2015; 38 Suppl 1:E441-5. [PMID: 25581356 PMCID: PMC6686168 DOI: 10.1002/hed.24015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 12/18/2014] [Accepted: 01/06/2015] [Indexed: 11/11/2022] Open
Abstract
Background The recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (SLN) are generally thought to innervate the endolaryngeal muscles and the cricothyroid muscle (CTM), respectively. Meticulous anatomic studies found communication between these nerves (ie, the human communicating nerve). In this study, we report the innervation of the CTM by the RLN. Methods We performed electromyographic studies of 50 patients during thyroidectomy (20 total and 30 hemithyroidectomies). During surgery, the external branch of the SLN, RLN, and vagus nerve were stimulated. Responses were evaluated by visual observation of the CTM and by electromyographies through needle electrodes inserted into the CTM. Results Seventy CTMs were evaluated. The RLN stimulation yielded both visible contractions and clear electromyographic responses (>300 µV) in 27 (39%), either response in 24 (34%), and neither response in 19 (27%) of the CTMs. The vagus stimulation gave similar results. Conclusion The RLN innervated the CTM at least in 39% cases. © 2015 The Authors. Head & Neck Published by Wiley Periodicals, Inc. Head Neck38: E441–E445, 2016
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