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Chen J, Lin Z, Xu B, Lu T, Zhang X. The efficacy and assessment value of the level of thyroglobulin wash-out after fine-needle aspiration cytodiagnosis in the evaluation of lymph node metastasis in papillary thyroid carcinoma. World J Surg Oncol 2024; 22:149. [PMID: 38840197 PMCID: PMC11151531 DOI: 10.1186/s12957-024-03430-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/27/2024] [Indexed: 06/07/2024] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy and clinical value of US, FNAC,FNA-Tg and FNAC + FNA-Tg, as well as the cutoff values of FNA-Tg to evaluate LN metastasis. METHODS We analyzed the diagnostic value of different US signs, the efficiency of US, FNAC, FNA-Tg and FNAC + FNA-Tg among the LN- and LN + groups, and the cutoff value of FNA-Tg to evaluate LN metastasis. We punctured LNs multiple times and measured the levels of FNA-Tg. Furthermore, the LNs were marked with immunohistochemical Tg and LCA to distinguish the presence of Tg in the para-cancerous tissue of the LNs. RESULTS The s-Tg and FNA-Tg of the LN + group were higher than those of the LN- group (P = 0.018, ≤ 0.001). The LN + group had more abnormal US signs than the LN- group. The cutoff value of FNA-Tg was 3.2 ng/mL. US had a high sensitivity (92.42), but the specificity was not satisfactory (55.1). FNA-Tg had a higher sensitivity (92.42 vs. 89.39), specificity (100 vs. 93.88), and accuracy (92.42 vs. 83.27) than FNAC. However, the sensitivity of FNAC + FNA-Tg increased further, while the specificity and accuracy decreased slightly. The presence of Tg in the normal lymphocytes adjacent to the cancer was confirmed. CONCLUSION Ultrasonography provides a noninvasive, dynamic, multidimensional assessment of LNs. With a cutoff value of 3.2 ng/mL, FNA-Tg has higher accuracy and a lower false-negative rate than various single diagnoses. However, FNAC combined with FNA-Tg does not cause additional pain to patients and offers a higher diagnostic efficacy and clinical value.
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Affiliation(s)
- Jie Chen
- Thyroid and Breast Surgery, Department of General Surgery, Wanbei Coal and Power Group General Hospital affiliated With Bengbu Medical University, Su Zhou, Anhui Province, China
| | - Zongwu Lin
- Thyroid and Breast Surgery, Department of General Surgery, Wanbei Coal and Power Group General Hospital affiliated With Bengbu Medical University, Su Zhou, Anhui Province, China
| | - Bo Xu
- Thyroid and Breast Surgery, Department of General Surgery, Wanbei Coal and Power Group General Hospital affiliated With Bengbu Medical University, Su Zhou, Anhui Province, China
| | - Tianwen Lu
- Thyroid and Breast Surgery, Department of General Surgery, Wanbei Coal and Power Group General Hospital affiliated With Bengbu Medical University, Su Zhou, Anhui Province, China
| | - Xinghai Zhang
- Thyroid and Breast Surgery, Department of General Surgery, Wanbei Coal and Power Group General Hospital affiliated With Bengbu Medical University, Su Zhou, Anhui Province, China.
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Wang SR, Li QL, Tian F, Li J, Li WX, Chen M, Sang T, Cao CL, Shi LN. Diagnostic value of multiple diagnostic methods for lymph node metastases of papillary thyroid carcinoma: A systematic review and meta-analysis. Front Oncol 2022; 12:990603. [PMID: 36439514 PMCID: PMC9686443 DOI: 10.3389/fonc.2022.990603] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 10/05/2022] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE This study compared the diagnostic value of various diagnostic methods for lymph node metastasis (LNM) of papillary thyroid carcinoma (PTC) through network meta-analysis. METHODS In this experiment, databases such as CNKI, Wanfang, PubMed, and Web of Science were retrieved according to the Cochrane database, Prisma, and NMAP command manual. A meta-analysis was performed using STATA 15.0, and the value of the surface under the cumulative ranking curve (SUCRA) was used to determine the most effective diagnostic method. Quality assessments were performed using the Cochrane Collaboration's risk of bias tool, and publication bias was assessed using Deeks' funnel plot. RESULTS A total of 38 articles with a total of 6285 patients were included. A total of 12 diagnostic methods were used to study patients with LNM of PTC. The results showed that 12 studies were direct comparisons and 8 studies were indirect comparisons. According to the comprehensive analysis of the area of SUCRA, US+CT(86.8) had the highest sensitivity, FNAC had the highest specificity (92.4) and true positive predictive value (89.4), and FNAC+FNA-Tg had higher negative predictive value (99.4) and accuracy (86.8). In the non-invasive method, US+CT had the highest sensitivity, and the sensitivity (SEN) was [OR=0.59, 95% confidence interval (CI): (0.30, 0.89]. Among the invasive methods, the combined application of FNAC+FNA-Tg had higher diagnostic performance. The sensitivity was [OR=0.62, 95% CI: (0.26, 0.98)], the specificity (SPE) was [OR=1.12, 95% CI: (0.59, 1.64)], the positive predictive value was [OR=0.98, 95% CI: (0.59, 1.37)], the negative predictive value was [OR=0.64, 95% CI (0.38, 0.90)], and the accuracy was [OR=0.71, 95% CI: (0.31, 1.12)]. CONCLUSION In the non-invasive method, the combined application of US+CT had good diagnostic performance, and in the invasive method, the combined application of FNAC+FNA-Tg had high diagnostic performance, and the above two methods were recommended.
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Affiliation(s)
- Si-Rui Wang
- Department of Ultrasound, the First Affiliated Hospital of Medical College, Shihezi University, Shihezi, Xinjiang, China
- NHC Key Laboratory of Prevention and Treatment of Central Asia High Incidence Diseases (First Affiliated Hospital, School of Medicine, Shihezi University), Shihezi, Xinjiang, China
| | - Qiao-Li Li
- Department of Ultrasound, the First Affiliated Hospital of Medical College, Shihezi University, Shihezi, Xinjiang, China
- NHC Key Laboratory of Prevention and Treatment of Central Asia High Incidence Diseases (First Affiliated Hospital, School of Medicine, Shihezi University), Shihezi, Xinjiang, China
| | - Feng Tian
- Department of Neurology, the First Affiliated Hospital of Medical College, Shihezi University, Shihezi, Xinjiang, China
| | - Jun Li
- Department of Ultrasound, the First Affiliated Hospital of Medical College, Shihezi University, Shihezi, Xinjiang, China
- NHC Key Laboratory of Prevention and Treatment of Central Asia High Incidence Diseases (First Affiliated Hospital, School of Medicine, Shihezi University), Shihezi, Xinjiang, China
| | - Wen-Xiao Li
- Department of Ultrasound, the First Affiliated Hospital of Medical College, Shihezi University, Shihezi, Xinjiang, China
- NHC Key Laboratory of Prevention and Treatment of Central Asia High Incidence Diseases (First Affiliated Hospital, School of Medicine, Shihezi University), Shihezi, Xinjiang, China
| | - Ming Chen
- Department of Ultrasound, the First Affiliated Hospital of Medical College, Shihezi University, Shihezi, Xinjiang, China
| | - Tian Sang
- Department of Ultrasound, the First Affiliated Hospital of Medical College, Shihezi University, Shihezi, Xinjiang, China
- NHC Key Laboratory of Prevention and Treatment of Central Asia High Incidence Diseases (First Affiliated Hospital, School of Medicine, Shihezi University), Shihezi, Xinjiang, China
| | - Chun-Li Cao
- Department of Ultrasound, the First Affiliated Hospital of Medical College, Shihezi University, Shihezi, Xinjiang, China
| | - Li-Nan Shi
- Department of Ultrasound, the First Affiliated Hospital of Medical College, Shihezi University, Shihezi, Xinjiang, China
- NHC Key Laboratory of Prevention and Treatment of Central Asia High Incidence Diseases (First Affiliated Hospital, School of Medicine, Shihezi University), Shihezi, Xinjiang, China
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3
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Du W, Fang Q, Dai L, Fan J. Fine-needle aspiration biopsy versus frozen section examination in assessing cervical lymph node metastasis in primary clinically positive neck papillary thyroid carcinoma. Diagn Cytopathol 2022; 50:217-222. [PMID: 35103414 DOI: 10.1002/dc.24935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Both fine-needle aspiration biopsy (FNAB) and frozen section (FS) examination are reliable methods for assessing cervical lymph node (level II-V) metastasis (LNM) in papillary thyroid carcinoma (PTC). Our goal was to compare the diagnostic accuracy of FNAB and FS in clinically positive neck (cN+) PTC patients. METHODS Altogether, 264 lymph node samples from 220 patients were prospectively enrolled. Samples were assessed by FNAB cytology (FNAB-C), thyroglobulin (Tg) FNAB needle wash testing (FNAB-Tg), and FS simultaneously. Diagnostic performance of the different methods were analyzed by the Chi-square test. RESULTS The sensitivity and specificity of FNAB-C alone in predicting LNM was 87.4% and 85.7%, respectively. Combined with FNAB-Tg, the sensitivity and specificity of FNAB-C increased to 98.9% and 81.6%, respectively. The sensitivity and specificity of FS in predicting LNM was 92.4% and 81.1%, respectively. FNAB-C and FNAB-Tg had better sensitivity than FS when applied to solid lymph nodes, and comparable sensitivity when applied to cystic and cystic-solid lymph nodes. CONCLUSION The utilization of FNAB-Tg significantly improved the diagnostic ability of FNAB-C. FS can be replaced by preoperative FNAB combined with FNAB-Tg without compromising diagnostic accuracy.
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Affiliation(s)
- Wei Du
- Department of Head Neck and Thyroid, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, PR China
| | - Qigen Fang
- Department of Head Neck and Thyroid, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, PR China
| | - Liyuan Dai
- Department of Head Neck and Thyroid, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, PR China
| | - Jie Fan
- Department of Head Neck and Thyroid, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, PR China
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4
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Wu X, Liu Y, Li K, Yang Y, Lai P, Li J, Kou S. Predictive Value of FNA-Tg and TgAb in Cervical Lymph Node Metastasis of Papillary Thyroid Carcinoma. Technol Cancer Res Treat 2022; 21:15330338221127605. [PMID: 36128843 PMCID: PMC9500251 DOI: 10.1177/15330338221127605] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objectives: To analyze whether thyroglobulin (Tg) and anti-Tg antibody (TgAb) detection in fine-needle aspiration (FNA) of cervical lymph node (LN; LN-FNA-Tg and LN-FNA-TgAb) can predict LN metastasis and obtain the best cutoff value. Methods: The patients admitted to our hospital from January 2020 to March 2021 were prospectively enrolled. The LNs were sampled by FNA. All patients underwent thyroid surgery and neck dissection. LN-FNA-Tg, LN-FNA-TgAb, and blood Tg and TgAb were measured. The receiver operating characteristic curve analysis was used to determine the best cutoff points for positive LN. Results: There were 29 participants in the LN metastasis group and 42 in the nonmetastasis group. Compared with the nonmetastasis group, the participants in the metastasis group had higher LN-FNA-Tg (median: 1897 vs 7.74 ng/mL, P < .001), higher LN-FNA-TgAb (median: 15.65 vs 8.21 IU/mL, P < .001), and higher serum Tg (median: 25.4 vs 18.81 ng/mL); there were no differences in serum TgAb (median: 26.6 vs 28.6 IU/mL, P = .477). The best accuracy (87.5%) was observed with LN-FNA-Tg of >227.1 ng/mL, resulting in an area under the curve of 0.927, 84.5% sensitivity, and 89.5% specificity. LN-FNA-TgAb >10.85 IS/mL had an accuracy of 79.6%, sensitivity 64.8%, and specificity 89.5%. Serum Tg and TgAb had the lowest accuracy, with 64.2% and 57.4%, respectively, sensitivity of 53.5% and 67.6%, and specificity of 71.4% and 50.5%. Similar results were observed in first-operation participants and postoperative participants. Conclusions: LN-FNA-Tg has high accuracy, sensitivity, and specificity for detecting cervical LN in patients with papillary thyroid cancer.
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Affiliation(s)
- Xiaoli Wu
- Department of Ultrasonography, 159410Panzhihua Central Hospital, Panzhihua, Sichuan, China
| | - Yan Liu
- Department of Ultrasonography, 159410Panzhihua Central Hospital, Panzhihua, Sichuan, China
| | - Keji Li
- Department of Ultrasonography, 159410Panzhihua Central Hospital, Panzhihua, Sichuan, China
| | - Yinghong Yang
- Department of General Surgery, 159410Panzhihua Central Hospital, Panzhihua, Sichuan, China
| | - Ping Lai
- Department of Ultrasonography, 159410Panzhihua Central Hospital, Panzhihua, Sichuan, China
| | - Jing Li
- Department of Laboratory Medicine, 159410Panzhihua Central Hospital, Panzhihua, Sichuan, China
| | - Sen Kou
- Department of Ultrasonography, 159410Panzhihua Central Hospital, Panzhihua, Sichuan, China
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Hajian M, Esmaeili A, Talebi A. Comparative evaluation of BMI-1 proto-oncogene expression in normal tissue, adenoma and papillary carcinoma of human thyroid in pathology samples. BMC Res Notes 2021; 14:369. [PMID: 34551814 PMCID: PMC8456638 DOI: 10.1186/s13104-021-05771-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 09/01/2021] [Indexed: 11/14/2022] Open
Abstract
Objective Papillary Thyroid carcinoma accounts for more than 60% of adult thyroid carcinomas. Finding a helpful marker is vital to determine the correct treatment approach. The present study was aimed to evaluate the expression of the B cell-specific Moloney murine leukemia virus integration site 1 (BMI-1) gene in papillary carcinoma, adenoma, and adjacent healthy thyroid tissues. Pathology blocks of thyroid tissues at the pathology department of patients who have undergone thyroid surgery between 2015 and 2019 were examined; papillary carcinoma, adenoma, and healthy tissues were selected and sectioned. Total RNA was extracted, and the relative expression level of the BMI-1 gene was examined using the Real-Time qPCR method. Results In the papillary and adenoma tissues, BMI-1 was overexpressed (1.047-fold and 1.042-fold) in comparison to healthy tissues (p < 0.05 for both comparisons). However, no statistically significant differences were observed between adenoma and papillary carcinoma tissues regarding BMI-1 gene expression. This study demonstrated a new biomarker for thyroid malignancies and found that the mRNA levels of the BMI-1 gene were higher in tumor tissues compared with healthy tissues. Further studies are needed to evaluate the BMI1 gene expression in other thyroid cancers.
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Affiliation(s)
- Mohadeseh Hajian
- Department of Pathology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abolghasem Esmaeili
- Department of Cell and Molecular Biology, University of Isfahan, Isfahan, Iran.
| | - Ardeshir Talebi
- Department of Pathology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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6
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Jia X, Wang Y, Liu Y, Wang X, Yao X, Tao R, Liu H, Yang A, Gao R. Thyroglobulin Measurement Through Fine-Needle Aspiration for Optimizing Neck Node Dissection in Papillary Thyroid Cancer. Ann Surg Oncol 2021; 29:88-96. [PMID: 34386915 PMCID: PMC8677638 DOI: 10.1245/s10434-021-10549-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 07/14/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Thyroglobulin measurement in fine-needle aspiration (FNA-Tg) is an additional diagnostic tool of lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC). However, its performance as a preoperative indicator of lateral neck LNM in PTC is unclear. We evaluated the use of FNA cytology and FNA-Tg to detect neck LNM presurgery using a simple methodology, and established a cut-off value for diagnosing LNM in PTC. METHODS We performed a retrospective cohort study based on hospital records, including 299 FNA-Tg measurements from 228 patients with PTC. The cut-off value for FNA-Tg was obtained through a receiver operating characteristic (ROC) curve analysis. The relationships between various parameters and FNA-Tg were analyzed using Spearman's correlation. RESULTS Of 299 lymph nodes (LNs) from 228 patients following surgery, 151 were malignant and 148 were benign. The median FNA-Tg levels were 414.40 ng/mL and 6.36 ng/mL in the metastatic and benign LNs, respectively. An FNA-Tg cut-off value of 28.3 ng/mL had the best diagnostic performance (93.38% sensitivity, 70.27% specificity, area under the ROC curve [AUC] 0.868) in the whole cohort. The diagnostic value performed better in the lateral neck group (level II-V, n = 163) than in the central neck group (level VI, n = 136); in the lateral neck group, the sensitivity and specificity of the FNA-Tg cut-off (16.8 ng/mL) were 96.25% and 96.36%, respectively. CONCLUSIONS FNA-Tg is a useful technique for the diagnosis of LNM before surgery, especially in lateral neck dissection. CLINICAL TRIAL REGISTRATION NUMBER ChiCTR1900028547.
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Affiliation(s)
- Xi Jia
- Department of Nuclear Medicine, The First Affiliated Hospital of Xian Jiaotong University, Xi'an, Shaanxi, China
| | - Yuanbo Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of Xian Jiaotong University, Xi'an, Shaanxi, China
| | - Yan Liu
- Department of Nuclear Medicine, The First Affiliated Hospital of Xian Jiaotong University, Xi'an, Shaanxi, China
| | - Xiang Wang
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xiaobao Yao
- Department of Otorhinolaryngology - Head and Neck Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Runyi Tao
- Department of Thoracic Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hui Liu
- Biobank, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Aimin Yang
- Department of Nuclear Medicine, The First Affiliated Hospital of Xian Jiaotong University, Xi'an, Shaanxi, China
| | - Rui Gao
- Department of Nuclear Medicine, The First Affiliated Hospital of Xian Jiaotong University, Xi'an, Shaanxi, China.
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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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Affiliation(s)
- Ohad Ronen
- Department of Otolaryngology - Head and Neck Surgery, Galilee Medical Center, affiliated with Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - K Thomas Robbins
- Department of Otolaryngology Head and Neck Surgery, Southern Illinois University Medical School, Springfield, Illinois, USA
| | - Kerry D Olsen
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ashok R Shaha
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Iain J Nixon
- Department of Otorhinolaryngology Head and Neck Surgery, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Mark E Zafereo
- Head and Neck Endocrine Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dana M Hartl
- Department of Otolaryngology-Head and Neck Surgery, Institut Gustave Roussy, Villejuif Cedex, France.,Laboratoire de Phonétique et de Phonologie, Paris, France
| | - Luiz P Kowalski
- Department of Otorhinolaryngology-Head and Neck Surgery, A.C. Camargo Cancer Center, São Paulo, Brazil.,Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Juan P Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias-ISPA, Oviedo, Spain.,Department of Otolaryngology, University of Oviedo-IUOPA, Oviedo, Spain.,Head and Neck Cancer Unit, CIBERONC, Madrid, Spain
| | - Andrés Coca-Pelaz
- Department of Otolaryngology, Hospital Universitario Central de Asturias-ISPA, Oviedo, Spain.,Department of Otolaryngology, University of Oviedo-IUOPA, Oviedo, Spain.,Head and Neck Cancer Unit, CIBERONC, Madrid, Spain
| | - Antti A Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Vincent Vander Poorten
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Oncology, Section Head and Neck Oncology, KU Leuven, Leuven, Belgium
| | - Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia/Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Department of Surgery, CEXCA-Centro de Excelencia en Enfermedades de Cabeza y Cuello, Medellín, Colombia
| | - Peter Angelos
- Department of Surgery and MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA
| | - Alessandra Rinaldo
- Department of Otolaryngology, University of Udine School of Medicine, Udine, Italy
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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