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Romesser PB, Sherman EJ, Whiting K, Ho ML, Shaha AR, Sabra MM, Riaz N, Waldenberg TE, Sabol CR, Ganly I, McBride SM, Fagin JA, Zhang Z, Tuttle RM, Wong RJ, Lee NY. Intensity-modulated radiation therapy and doxorubicin in thyroid cancer: A prospective phase 2 trial. Cancer 2021; 127:4161-4170. [PMID: 34293201 DOI: 10.1002/cncr.33804] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/11/2021] [Accepted: 06/04/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND The use of external-beam radiotherapy for locally advanced nonanaplastic thyroid cancer remains controversial. This prospective study evaluated the efficacy and tolerability of intensity-modulated radiation therapy (IMRT) with or without concurrent chemotherapy in patients with locally advanced thyroid cancer. METHODS The authors conducted a nonrandomized phase 2 trial of IMRT with or without concurrent doxorubicin in patients with gross residual or unresectable nonanaplastic thyroid carcinoma (ClinicalTrials.gov identifier NCT01882816). The primary end point was 2-year locoregional progression-free survival (PFS). Secondary end points included overall survival (OS), safety, patient-reported outcomes, and functional outcomes. RESULTS Twenty-seven patients were enrolled: 12 (44.4%) with unresectable disease and 15 (55.6%) with gross residual disease. The median follow-up was 45.6 months (interquartile range, 42.0-51.6 months); the 2-year cumulative incidences of locoregional PFS and OS were 79.7% and 77.3%, respectively. The rate of grade 3 or higher acute and late toxicities was 33.4%. There were no significant functional differences 12 months after treatment (assessed objectively by the modified barium swallow study). Patient-reported quality of life in the experimental group was initially lower but returned to the baseline after 6 months and improved thereafter. In a post hoc analysis, concurrent chemotherapy with intensity-modulated radiation therapy (CC-IMRT) resulted in significantly less locoregional failure at 2 years (no failure vs 50%; P = .001), with higher rates of grade 2 or higher acute dermatitis, mucositis, and dysphagia but no difference in long-term toxicity, functionality, or patient-reported quality of life. CONCLUSIONS In light of the excellent locoregional control rates achieved with CC-IMRT and its acceptable toxicity profile as confirmed by functional assessments and patient-reported outcomes, CC-IMRT may be preferred over IMRT alone.
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Li H, Livneh N, Dogan S, Shaha AR. The Growth Kinetics of Collision Nodal Metastasis from Medullary and Papillary Thyroid Carcinomas: A Case Report. Eur Thyroid J 2021; 10:345-352. [PMID: 34395307 PMCID: PMC8314775 DOI: 10.1159/000511184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION The collision of medullary (MTC) and papillary thyroid carcinoma (PTC) in the same cervical lymph node can occur, but its growth kinetics has not been reported. CASE PRESENTATION We report a 27-year-old male patient who had collision nodal metastases from PTC and sporadic MTC in the central compartment. This was treated with total thyroidectomy and central neck dissection. The collision nodal metastasis persisted and presented with a single sonographically enlarging central compartmental lymph node postoperatively. The volume of the collision nodal metastasis increased from 226 to 507 mm3 over the first 8 months, from 507 to 572 mm3 over the next 6 months, and from 572 to 762 mm3 over the next 31 months. The calcitonin and carcinoembryonic antigen (CEA) fluctuated in the first 19 months followed by a steady increase at a doubling time of 1.97 and 8.42 years, respectively. Unstimulated thyroglobulin remained at 0.2 ng/mL or lower during the same period while thyrotropin (TSH) was not suppressed. Revision central neck dissection performed 4.5 years later resulted in undetectable serum calcitonin, CEA of 2 ng/mL, and thyroglobulin of 0.1 ng/mL from a preoperative calcitonin of 212 ng/L, CEA of 10 ng/mL, and thyroglobulin of 0.2 ng/mL. Further structural imaging 13.5 months later revealed no evidence of disease. DISCUSSION The growth kinetics of collision nodal metastasis from PTC and MTC can be similar to conventional PTC and MTC. Furthermore, the growth rate of such collision nodal metastases can be slow. Guided by tumor marker doubling time and regular structural imaging, surgical salvage performed after a period of active surveillance may still result in biochemical and structural remission.
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Spanheimer PM, Ganly I, Chou JF, Capanu M, Nigam A, Ghossein RA, Tuttle RM, Wong RJ, Shaha AR, Brennan MF, Untch BR. Prophylactic Lateral Neck Dissection for Medullary Thyroid Carcinoma is not Associated with Improved Survival. Ann Surg Oncol 2021; 28:6572-6579. [PMID: 33748897 DOI: 10.1245/s10434-021-09683-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/20/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients with medullary thyroid carcinoma (MTC) often receive lateral lymph node dissection with total thyroidectomy when calcitonin levels are elevated, even in the absence of structural disease, but the effect of this intervention on disease-specific outcomes is not known. PATIENTS AND METHODS We retrospectively reviewed patients from 1986 to 2017 who underwent thyroidectomy with curative intent for MTC at our institution. The association of disease-specific survival and clinicopathologic features was examined using univariate and multivariate Cox regression. RESULTS We identified 316 patients who underwent curative resection for MTC. Overall and disease-specific survival were 76% and 86%, respectively, at 10 years. To investigate the effect of prophylactic ipsilateral lateral lymph node dissection, we analyzed 89 patients without known structural disease in the neck lymph nodes at the time of resection and preoperative calcitonin > 200 pg/ml, of whom 45 had an ipsilateral lateral lymph node dissection (LND) and 44 did not. There were no differences in tumor size or preoperative calcitonin levels. There was no difference at 10 years in cumulative incidence of recurrence in the neck (20.9% LND vs. 30.4% no LND, p = 0.46), cumulative incidence of distant recurrence (18.3% vs. 18.4%, p = 0.97), disease-specific survival (86% vs. 93%, p = 0.53), or overall survival (82% vs. 90%, p = 0.6). CONCLUSION Lateral neck dissection in the absence of clinical or radiologic abnormal lymph nodes is not associated with improved survival in patients with MTC.
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Shaha AR, Tuttle RM. Delphian node-A sentinel node in thyroid cancer? J Surg Oncol 2021; 123:1529-1530. [PMID: 33713440 DOI: 10.1002/jso.26441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 11/08/2022]
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Hartl DM, Zafereo ME, Kowalski LP, Randolph GW, Olsen KD, Fernandez-Alvarez V, Nixon IJ, Shaha AR, Angelos P, Shah JP, Ferlito A. Occlusion of the internal jugular vein in differentiated thyroid carcinoma: Causes and diagnosis. Eur J Surg Oncol 2021; 47:1552-1557. [PMID: 33642089 DOI: 10.1016/j.ejso.2021.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/02/2021] [Accepted: 02/17/2021] [Indexed: 01/27/2023] Open
Abstract
Occlusion of the internal jugular vein (IJV) can be observed in thyroid cancer either on preoperative imaging with ultrasound or cross-sectional imaging, particularly contrast-enhanced CT-scan, and can be detected during follow-up when using these same imaging modalities. For thyroid cancer, four different causes of occlusion of the IJV can be identified: venous thrombosis associated with a hypercoagulable state, tumor thrombus in the vein, compression or invasion of the IJV by thyroid disease or lymph node metastases, and fibrotic collapse of the IJV following lateral neck dissection. Clinicians managing patients with thyroid cancer need to be aware of and able to diagnose each of these conditions. The overall patient impact and appropriate management of each will be discussed.
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Shaha AR, Tuttle RM, Wreesmann VB. Management of the contralateral central neck in differentiated thyroid cancer: A contentious issue. Eur J Surg Oncol 2021; 47:717-719. [PMID: 33608179 DOI: 10.1016/j.ejso.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/01/2022] Open
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Tufano RP, Pace-Asciak P, Russell JO, Suárez C, Randolph GW, López F, Shaha AR, Mäkitie A, Rodrigo JP, Kowalski LP, Zafereo M, Angelos P, Ferlito A. Update of Radiofrequency Ablation for Treating Benign and Malignant Thyroid Nodules. The Future Is Now. Front Endocrinol (Lausanne) 2021; 12:698689. [PMID: 34248853 PMCID: PMC8264548 DOI: 10.3389/fendo.2021.698689] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/27/2021] [Indexed: 12/12/2022] Open
Abstract
Thermal and chemical ablation are minimally invasive procedures that avoid removal of the thyroid gland and target symptomatic nodules directly. Internationally, Radiofrequency ablation (RFA) is among one of the most widely used thermal ablative techniques, and is gaining traction in North America. Surgery remains the standard of care for most thyroid cancer, and in the right clinical setting, Active Surveillance (AS) can be a reasonable option for low risk disease. Minimally invasive techniques have emerged as an alternative option for patients deemed high risk for surgery, or for those patients who wish to receive a more active treatment approach compared to AS. Herein, we review the literature on the safety and efficacy of RFA for treating benign non-functioning thyroid nodules, autonomously functioning thyroid nodules, primary small low risk thyroid cancer (namely papillary thyroid cancer) as well as recurrent thyroid cancer.
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Patel SG, Atkinson TM, Tuttle RM, Pusic AL, Shah JP, Shaha AR, Lynch K, DiLorenzo M, Ali S, Wong RJ, Cracchiolo JR. ThyroidEx: Development and Preliminary Validation of a Thyroid Surgery Expectations Measure. Otolaryngol Head Neck Surg 2020; 165:267-274. [PMID: 33320788 DOI: 10.1177/0194599820976317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To address the lack of validated patient-reported outcome (PRO) instruments that define and quantify patient expectations in thyroid cancer surgery, we developed and initially validated ThyroidEx, a novel disease-specific PRO instrument. STUDY DESIGN Survey study. SETTING Single-institution tertiary care cancer center. METHODS An expert panel drafted an initial set of thyroid cancer-specific concepts, which was used in semistructured concept elicitation interviews with patients with thyroid cancer 4 weeks before and 8 weeks after surgery. Candidate items were generated per patient responses and refined via cognitive interviewing and additional review by the expert panel. The draft ThyroidEx was then preoperatively administered to a separate cohort undergoing thyroid cancer surgery to establish a final item set and initial psychometric evidence. RESULTS Prospective concept elicitation interviews generated 358 patient-elicited concepts (n = 15 patients). These were then placed into 70 unique subcategories from which 41 items were generated for cognitive interviews with 20 patients preoperatively and 28 postoperatively. After expert panel review, ThyroidEx included 18 items across 2 scales (Expectations and Concerns), with an additional item about beliefs. In the preoperative cohort in phase 2 (n = 67), internal consistency Cronbach's α values ranged from 0.81 to 0.89. Descriptive analysis showed significant differences between patients' concerns and expectations and clinicians' perceptions. CONCLUSION Defining expectations represents an important modifier in the measurement of PROs. Preliminary validation of ThyroidEx revealed incongruent expectations between expert opinion and patients. Future development and implementation of ThyroidEx may affect preoperative consultation and the consent process.
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Shaha AR, Tuttle RM. Commentary: Re-recurrence after surgical management of recurrent thyroid cancer. Surgery 2020; 169:844-845. [PMID: 33250199 DOI: 10.1016/j.surg.2020.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/25/2022]
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Asimakopoulos P, Shaha AR, Nixon IJ, Shah JP, Randolph GW, Angelos P, Zafereo ME, Kowalski LP, Hartl DM, Olsen KD, Rodrigo JP, Vander Poorten V, Mäkitie AA, Sanabria A, Suárez C, Quer M, Civantos FJ, Robbins KT, Guntinas-Lichius O, Hamoir M, Rinaldo A, Ferlito A. Management of the Neck in Well-Differentiated Thyroid Cancer. Curr Oncol Rep 2020; 23:1. [PMID: 33190176 DOI: 10.1007/s11912-020-00997-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW In this narrative review, we discuss the indications for elective and therapeutic neck dissections and the postoperative surveillance and treatment options for recurrent nodal disease in patients with well-differentiated thyroid cancer. RECENT FINDINGS Increased availability of advanced imaging modalities has led to an increased detection rate of previously occult nodal disease in thyroid cancer. Nodal metastases are more common in young patients, large primary tumors, specific genotypes, and certain histological types. While clinically evident nodal disease in the lateral neck compartments has a significant oncological impact, particularly in the older age group, microscopic metastases to the central or the lateral neck in well-differentiated thyroid cancer do not significantly affect outcome. As patients with clinically evident nodal disease are associated with worse outcomes, they should be treated surgically in order to reduce rates of regional recurrence and improve survival. The benefit of elective neck dissection remains unverified as the impact of microscopic disease on outcomes is not significant.
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Civantos FJ, Vermorken JB, Shah JP, Rinaldo A, Suárez C, Kowalski LP, Rodrigo JP, Olsen K, Strojan P, Mäkitie AA, Takes RP, de Bree R, Corry J, Paleri V, Shaha AR, Hartl DM, Mendenhall W, Piazza C, Hinni M, Robbins KT, Tong NW, Sanabria A, Coca-Pelaz A, Langendijk JA, Hernandez-Prera J, Ferlito A. Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era. Front Oncol 2020; 10:593164. [PMID: 33244460 PMCID: PMC7685177 DOI: 10.3389/fonc.2020.593164] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 09/30/2020] [Indexed: 12/20/2022] Open
Abstract
Background Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur. Methods We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts. Results Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy. Conclusions New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.
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Guntinas-Lichius O, Thielker J, Robbins KT, Olsen KD, Shaha AR, Mäkitie AA, de Bree R, Vander Poorten V, Quer M, Rinaldo A, Kowalski LP, Rodrigo JP, Hamoir M, Ferlito A. Prognostic role of intraparotid lymph node metastasis in primary parotid cancer: Systematic review. Head Neck 2020; 43:997-1008. [PMID: 33169420 DOI: 10.1002/hed.26541] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/30/2020] [Accepted: 10/30/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The prognostic importance of intraparotid lymph node metastasis (P+) in patients with primary parotid gland carcinoma is unclear. METHODS Nineteen retrospective and noncomparative cohort studies, published between 1992 and 2020, met the inclusion criteria and included 2202 patients for this systematic review. RESULTS The pooled prevalence of the P in adult patients in the unselected studies was 24.10% (95% confidence interval = 17.95-30.25). The number of P+ lymph nodes per patient was counted in only three studies and ranged from 1 to 11. The 5-year recurrence-free survival rate based on Kaplan-Meier analysis varied from 83% to 88% in P- patients compared to 36% to 54% in P+ patients. The average hazard ratio for tumor recurrence in patients with P+ compared to P- was 2.67 ± 0.58. CONCLUSIONS P+ is an independent negative prognostic factor in primary parotid gland cancer and should be included into the treatment planning.
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Simó R, Nixon IJ, Rovira A, Vander Poorten V, Sanabria A, Zafereo M, Hartl DM, Kowalski LP, Randolph GW, Kamani D, Shaha AR, Shah J, Marie JP, Rinaldo A, Ferlito A. Immediate Intraoperative Repair of the Recurrent Laryngeal Nerve in Thyroid Surgery. Laryngoscope 2020; 131:1429-1435. [PMID: 33118630 DOI: 10.1002/lary.29204] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/02/2020] [Accepted: 09/30/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Recurrent laryngeal nerve (RLN) injury is a recognized risk during thyroid and parathyroid surgery and can result in significant morbidity. The aim of this review paper is to consider the optimal approach to the immediate intraoperative repair of the RLN during thyroid surgery. METHODS A PubMed literature search was performed from inception to June 2020 using the following search strategy: immediate repair or repair recurrent laryngeal nerve, repair or reinnervation recurrent laryngeal nerve and immediate neurorraphy or neurorraphy recurrent laryngeal nerve. RESULTS Methods of immediate intraoperative repair of the RLN include direct end-to-end anastomosis, free nerve graft anastomosis, ansa cervicalis to RLN anastomosis, vagus to RLN anastomosis, and primary interposition graft. Techniques of nerve repair include micro-suturing, use of fibrin glue, and nerve grafting. Direct micro-suture is preferable when the defect can be repaired without tension. Fibrin glue has also been proposed for nerve repair but has been criticized for its toxicity, excessive slow reabsorption, and the risk of inflammatory reaction in the peripheral tissues. When the proximal stump of the RLN cannot be used, grafting could be done using transverse cervical nerve, supraclavicular nerve, vagus nerve, or ansa cervicalis. CONCLUSIONS Current evidence is low-level; however, it suggests that when the RLN has been severed, avulsed, or sacrificed during thyroid surgery it should be repaired intraoperatively. The immediate repair has on balance more advantages than disadvantages and should be considered whenever possible. This should enable the maintenance of vocal cord tone, better and prompter voice recovery and avoidance of aspiration. Laryngoscope, 131:1429-1435, 2021.
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Shaha AR, Patel KN, Michael Tuttle R. Completion thyroidectomy-Have we made appropriate decisions? J Surg Oncol 2020; 123:37-38. [PMID: 33098667 DOI: 10.1002/jso.26234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/09/2022]
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Ronen O, Robbins KT, Olsen KD, Shaha AR, Randolph GW, Nixon IJ, Zafereo ME, Hartl DM, Kowalski LP, Rodrigo JP, Coca-Pelaz A, Mäkitie AA, Vander Poorten V, Sanabria A, Angelos P, Rinaldo A, Ferlito A. Case for staged thyroidectomy. Head Neck 2020; 42:3061-3071. [PMID: 32761849 DOI: 10.1002/hed.26393] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/01/2020] [Accepted: 07/09/2020] [Indexed: 12/14/2022] Open
Abstract
Recent modifications in the management of well-differentiated thyroid cancer have resulted in significant alterations in clinical approach. Utilizing a series of preoperative and postoperative risk factors involving both the patient and the disease pathology, we offer the term "staged thyroidectomy" to help organize these risk factors for patients and the endocrine team to optimize management. This approach is intended to incorporate our latest nuanced understanding of certain endocrine pathology and may serve to optimize patient outcomes.
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Harries V, McGill M, Wang LY, Tuttle RM, Wong RJ, Shaha AR, Shah JP, Patel SG, Ganly I. Is a Prophylactic Central Compartment Neck Dissection Required in Papillary Thyroid Carcinoma Patients with Clinically Involved Lateral Compartment Lymph Nodes? Ann Surg Oncol 2020; 28:512-518. [PMID: 32681478 DOI: 10.1245/s10434-020-08861-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 06/29/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND The 2015 American Thyroid Association guidelines state that a prophylactic central compartment neck dissection (PCND) should be considered for patients with papillary thyroid carcinoma (PTC) and clinically involved lateral neck lymph nodes (cN1b). The purpose of our study was to determine the rate of central neck recurrence in select cN1b patients, with no evidence of clinically involved central compartment lymph nodes, treated without a PCND. METHODS After institutional review board approval, adult PTC patients with cN1b disease who were treated with a total thyroidectomy and lateral neck dissection were identified from an institutional database of 6259 patients who underwent initial surgery for well-differentiated thyroid carcinoma from 1986 to 2015. Patients with gross extrathyroidal extension, distant metastases, or no preoperative imaging were excluded. Patients with evidence of clinically involved central compartment lymph nodes, on preoperative imaging or intraoperative evaluation, also were excluded. A total of 152 cN1b patients were included and categorized into non-PCND and PCND groups. Central neck recurrence-free probability (CNRFP) was calculated using the Kaplan-Meier method and log-rank tests. RESULTS One hundred three patients (67.8%) did not have a PCND. With a median follow-up of 65 months, the 5- and 10-year CNRFP was 98.4% in the non-PCND group and 93.6% in the PCND group (p = 0.133). CONCLUSIONS Select PTC patients with cN1b disease but no evidence of clinically involved central compartment lymph nodes, on preoperative imaging and intraoperative evaluation, appear to have a low rate of central neck recurrence. These patients may not require or benefit from a PCND.
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Shaha AR, Poorten VV, Tuttle RM. Multifocality in papillary thyroid carcinoma-An unresolved controversy. Eur J Surg Oncol 2020; 46:1777-1778. [PMID: 32646757 DOI: 10.1016/j.ejso.2020.06.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 10/24/2022] Open
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Kang JJ, Wong RJ, Sherman EJ, Rybkin A, McBride SM, Riaz N, Tsai CJ, Yu Y, Chen L, Zakeri K, Gelblum DY, Gillespie EF, Cohen MA, Cracchiolo JR, Ganly I, Patel S, Singh B, Boyle JO, Roman BR, Morris LG, Shaha AR, Dunn LA, Ho AL, Fetten JV, Shah JP, Pfister DG, Lee NY. The 3 Bs of cancer care amid the COVID-19 pandemic crisis: "Be safe, be smart, be kind"-A multidisciplinary approach increasing the use of radiation and embracing telemedicine for head and neck cancer. Cancer 2020; 126:4092-4104. [PMID: 32639615 PMCID: PMC7361524 DOI: 10.1002/cncr.33031] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/09/2020] [Indexed: 12/22/2022]
Abstract
Because of the national emergency triggered by the coronavirus disease 2019 (COVID-19) pandemic, government-mandated public health directives have drastically changed not only social norms but also the practice of oncologic medicine. Timely head and neck cancer (HNC) treatment must be prioritized, even during emergencies. Because severe acute respiratory syndrome coronavirus 2 predominantly resides in the sinonasal/oral/oropharyngeal tracts, nonessential mucosal procedures are restricted, and HNCs are being triaged toward nonsurgical treatments when cures are comparable. Consequently, radiation utilization will likely increase during this pandemic. Even in radiation oncology, standard in-person and endoscopic evaluations are being restrained to limit exposure risks and preserve personal protective equipment for other frontline workers. The authors have implemented telemedicine and multidisciplinary conferences to continue to offer standard-of-care HNC treatments during this uniquely challenging time. Because of the lack of feasibility data on telemedicine for HNC, they report their early experience at a high-volume cancer center at the domestic epicenter of the COVID-19 crisis.
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Guntinas-Lichius O, Volk GF, Olsen KD, Mäkitie AA, Silver CE, Zafereo ME, Rinaldo A, Randolph GW, Simo R, Shaha AR, Vander Poorten V, Ferlito A. Facial nerve electrodiagnostics for patients with facial palsy: a clinical practice guideline. Eur Arch Otorhinolaryngol 2020; 277:1855-1874. [PMID: 32270328 PMCID: PMC7286870 DOI: 10.1007/s00405-020-05949-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 03/27/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE Facial nerve electrodiagnostics is a well-established and important tool for decision making in patients with facial nerve diseases. Nevertheless, many otorhinolaryngologist-head and neck surgeons do not routinely use facial nerve electrodiagnostics. This may be due to a current lack of agreement on methodology, interpretation, validity, and clinical application. Electrophysiological analyses of the facial nerve and the mimic muscles can assist in diagnosis, assess the lesion severity, and aid in decision making. With acute facial palsy, it is a valuable tool for predicting recovery. METHODS This paper presents a guideline prepared by members of the International Head and Neck Scientific Group and of the Multidisciplinary Salivary Gland Society for use in cases of peripheral facial nerve disorders based on a systematic literature search. RESULTS Required equipment, practical implementation, and interpretation of the results of facial nerve electrodiagnostics are presented. CONCLUSION The aim of this guideline is to inform all involved parties (i.e. otorhinolaryngologist-head and neck surgeons and other medical specialists, therapeutic professionals and the affected persons) and to provide practical recommendations for the diagnostic use of facial nerve electrodiagnostics.
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Coca-Pelaz A, Shah JP, Hernandez-Prera JC, Ghossein RA, Rodrigo JP, Hartl DM, Olsen KD, Shaha AR, Zafereo M, Suarez C, Nixon IJ, Randolph GW, Mäkitie AA, Kowalski LP, Vander Poorten V, Sanabria A, Guntinas-Lichius O, Simo R, Zbären P, Angelos P, Khafif A, Rinaldo A, Ferlito A. Papillary Thyroid Cancer-Aggressive Variants and Impact on Management: A Narrative Review. Adv Ther 2020; 37:3112-3128. [PMID: 32488657 PMCID: PMC7467416 DOI: 10.1007/s12325-020-01391-1] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Indexed: 12/11/2022]
Abstract
Introduction Aggressive variants of papillary thyroid cancer (PTC) have been described with increasing frequency. These variants include diffuse sclerosing variant, tall cell variant, columnar cell variant, solid variant, and hobnail variant. Methods We have performed a review of the more aggressive variants of PTC with respect to main characteristics, histological and molecular features, and the consequences that the knowledge of these variants should have in the treatment of the patients. Results At the present time, we do not know the prognostic value of these aggressive PTC variants. The extent of the surgical treatment and adjuvant therapy necessary should be decided on the basis of the extent of the tumor at presentation and the opinion of experienced clinicians. Conclusion These aggressive variants should be known by clinicians, to avoid underdiagnosis, and treated according to the latest recommendations in the literature.
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Shaha AR, Ghossein R, Tuttle RM. Lymphovascular invasion and active surveillance in thyroid cancer. Eur J Surg Oncol 2020; 46:1775-1776. [PMID: 32694055 DOI: 10.1016/j.ejso.2020.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 11/19/2022] Open
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Wu JX, Hanson M, Lohia S, Li H, Wang L, Shaha AR, Ganly I. Prospective anatomical study to determine the site of insertion of recurrent laryngeal nerve into the larynx. Clin Otolaryngol 2020; 45:853-856. [PMID: 32578395 DOI: 10.1111/coa.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/13/2020] [Accepted: 05/25/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Determine whether the insertion site of the recurrent laryngeal nerve (RLN) occurs at a predictable distance from the midline trachea, to help guide safe dissection during thyroid surgery. DESIGN Prospective clinical trial. At the inferior edge of the cricoid cartilage, we measured the distance from mildline trachea to the RLN insertion site. SETTING Single institution. PARTICIPANTS 50 consecutive patients undergoing thyroid surgery. MAIN OUTCOME MEASURES Distance from midline trachea to laryngeal insertion of RLN. RESULTS The study population included 36 women and 14 men, with 72 total nerves measured. The average distance-to-midline + standard deviation (range) of the RLN was 20.7 + 2.3 (17-26) mm in women compared to 26.3 + 2.1 (22-32) mm in men. CONCLUSION The insertion point of the RLN into the larynx at the level of inferior border of the cricoid cartilage can be reliably predicted, to facilitate early identification of the RLN during thyroid surgery.
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Harries V, McGill M, Tuttle RM, Shaha AR, Wong RJ, Shah JP, Patel SG, Ganly I. Management of Retropharyngeal Lymph Node Metastases in Differentiated Thyroid Carcinoma. Thyroid 2020; 30:688-695. [PMID: 31910129 PMCID: PMC7232633 DOI: 10.1089/thy.2019.0359] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background: Retropharyngeal lymph node metastases (RPMs) from differentiated thyroid carcinoma (DTC) are rare. Treatment includes surgical resection, radioactive iodine (RAI) therapy, or external beam radiation therapy (EBRT). The objective of this study was to describe our experience in the management of DTC-associated RPMs. Methods: Patients diagnosed with a DTC-associated RPM from 1999 to 2018 were identified at our institution, using key search terms in imaging and histology reports. Patient and tumor characteristics were recorded, and patients were grouped according to RPM management: observation, nonsurgical treatment, or surgical resection. The estimated rates of local RPM control, disease-specific survival (DSS), and distant metastasis-free probability (DMFP) were calculated by using the Kaplan-Meier method. Results: Of the 65 patients identified, 53 (82%) had an RPM as a manifestation of recurrent disease. Twenty-five patients (38%) underwent observation, 13 (20%) received nonsurgical treatment (RAI, EBRT, and/or systemic therapy), and 27 (42%) underwent surgical resection. In the observation cohort, all patients had a stable RPM, which in the majority (80%) of cases remained <1.5 cm during the period of observation (median 28 months). Of the 13 patients in the nonsurgical treatment cohort, 3 received RAI therapy, 7 received EBRT, and 3 received systemic therapy only. In the surgical cohort, the median RPM maximum diameter was 2.0 cm (range 0.8-4.2 cm). The size of the RPM was predictive of surgical resection versus observation (p < 0.001). A transcervical approach was employed in 19 patients, and a transoral approach was used in 8 patients. The 5-year rate of local RPM control was 92%. For the whole cohort, the 5- and 10-year DMFP were 72% and 62%, respectively; the 5- and 10-year DSS were 93% and 81%, respectively. Conclusions: DTC-associated RPMs manifest as recurrent disease in the majority of patients. Select patients with a small-volume and nonprogressive RPM may be suitable for observation, whereas surgery is likely warranted in large or progressing RPMs. In general, the presence of an RPM from DTC appears to be associated with aggressive disease.
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Moussa AM, Maybody M, Gonzalez-Aguirre AJ, Buicko JL, Shaha AR, Santos E. Thoracic Duct Embolization in Post-neck Dissection Chylous Leakage: A Case Series of Six Patients and Review of the Literature. Cardiovasc Intervent Radiol 2020; 43:931-937. [PMID: 32342160 DOI: 10.1007/s00270-020-02475-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/30/2020] [Indexed: 02/01/2023]
Abstract
Chylous leak is a serious complication of neck dissection. Patients are often managed conservatively, and failure of conservative management necessitates surgical management, which adds to their morbidity. We present a case series demonstrating the value of thoracic duct embolization (TDE) in management of patients with chylous leaks following neck dissection who have failed conservative management and to review the literature on this specific application of TDE. Between 2011 and 2019, six patients underwent a total of seven TDE procedures. Lymphatic leak was identified, and clinical success was achieved in all patients, with one patient requiring repeat TDE. No minor or major complications were reported. In conclusion, TDE is a safe and effective tool in management of chylous leaks following neck dissection.
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Shaha AR. Thyroid surgery during COVID-19 pandemic: Principles and philosophies. Head Neck 2020; 42:1322-1324. [PMID: 32338793 PMCID: PMC7267442 DOI: 10.1002/hed.26198] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 11/25/2022] Open
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