Total thyroidectomy, without prophylactic central lymph node dissection, in the treatment of differentiated thyroid cancer. Clinical retrospective study on 221 cases

Role of computed tomography in the evaluation of regional metastasis in well-differentiated thyroid cancer

Background

Accurate neck staging is essential for performing appropriate surgery and avoiding undue morbidity in thyroid cancer. The modality of choice for evaluation is ultrasonography (US), which has limitations, particularly in the central compartment, that can be overcome by adding a computed tomography (CT).

Methods

A total of 314 nodal levels were analyzed in 43 patients with CT, and US; evaluations were done between January 2013 and November 2015. The images were reviewed by two radiologists independently who were blinded to histopathological outcomes. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of US, CT, and US + CT were calculated using histology as the gold standard.

Results

The overall sensitivity, specificity, PPV, and NPV for US, CT, and US + CT were 53.9%, 88.8%, 74.1%, and 76.4%; 81.2%, 68.0%, 60.1%, and 85.9%; and 84.6%, 66.0%, 59.6%, and 87.8%, respectively. The overall accuracy of the US was 75.80%, the CT scan was 72.93%, and the US + CT scan was 72.93%. For the lateral compartment, the sensitivity, specificity, PPV, and NPV for the US, CT, and US + CT were 56.6%, 91.4%, 77.1%, and 80.5%; 80.7%, 70.6%, 58.3%, and 87.8%; and 84.3%, 68.7%, 57.9%, and 89.6%, respectively. The accuracy of the US was 79.67%, the CT scan was 73.98%, and the US + CT scan was 73.98% for the lateral compartment. For the central compartment, the sensitivity, specificity, PPV, and NPV for the US, CT, and US + CT were 47.1%, 76.5%, 66.7%, and 59.1%; 82.4%, 55.9%, 65.1%, and 76.0%; and 85.3%, 52.9%, 64.4%, and 78.3%, respectively. The accuracy of the US was 61.76%, the CT scan was 69.12%, and the US + CT scan was 69.12% for the central compartment.

Conclusions

This study demonstrated that CT has higher sensitivity in detecting nodal metastasis; however, its role is complementary to US due to low specificity.

Post-Thyroidectomy Hypocalcemia: Clinical Study at Tertiary Care Center

A recent review by the American association of clinical Endocrinologist (AACE) and American College of Endocrinology discussed definations and management of post-surgical hypocalcemia. In term of post-surgical hypocalcemia a total serum calcium of less than 8.5 mg/Dl(2.125 mmol/L) or ionised calcium less than 1.15 mmol/L were considered as cut off levels. The aim of the study is to evaluate & compare 30 operated cases of thyroid surgery based on its gender, age distribution, pre-operative indication & nature of surgery, post-thyroidectomy hypocalcemia. This prospective study was conducted in the Department of Otorhinolaryngology, head, neck surgery department sir T hospital, and government medical college Bhavnagar. All patients undergoing thyroidectomy surgeries were included in the study. Data collected from the patients undergoing thyroidectomise by meticulous history taking, careful clinical examination, appropriate radiological, haematological investigations including serum calcium and serum albumin, operative findings and follow-up of the cases was done after surgery for post- in association with nature of thyroid surgery. Post-thyroidectomy transient hypocalcemia is a frequent complication which can be prevented with pre-operative preparation of patients with extreme caution and pre-operative meticulous dissection, prompt identification of parathyroids and post-operative frequent monitoring of serum calcium and early treatment can prevent significant morbidity. operative hypocalcemia. The study was conducted to know the incidence of hypocalcemia after thyroid surgery.

A Proposed Heterogeneous Ensemble Algorithm Model for Predicting Central Lymph Node Metastasis in Papillary Thyroid Cancer

Purpose

To develop a heterogeneous ensemble algorithm model to precisely predict central lymph node metastasis (CLNM), which can provide a reference value on controversial topics of performing prophylactic central lymph node dissection for patients with papillary thyroid cancer (PTC).

Methods

The study included patients with PTC who underwent an initial thyroid resection in a single-center medical institution between January 2014 and December 2018. A total of 18 variables, including clinical features and ultrasound (US) features, were used in the univariate analysis, multivariate analysis, and feature selection and were also used to develop a heterogeneous ensemble model based on five basic machine learning models, including extreme gradient boosting, k-nearest neighbors, random forest, gradient boosting, and AdaBoost. Moreover, a partial dependent plot was used to explain the heterogeneous ensemble model.

Results

The area under the receiver operating characteristic curve of the heterogeneous ensemble algorithm model was 0.67, which is significantly better than that of the basic machine models in predicting CLNM. All machine learning models performed better than US. Based on multivariate analysis and receiver operating characteristic curve analysis, age ≤33 years, tumor size ≥0.8 cm, US-suspected CLNM, and microcalcification were risk factors for CLNM, and anti-thyroid peroxidase antibody and serum thyroglobulin levels were favorable factors for CLNM.

Conclusion

The proposed heterogeneous ensemble algorithm model may be optimal tool to predict CLNM by integrating clinical and US features.

Treating Clinically Node-Negative Insular Thyroid Carcinoma without Prophylactic Central Compartment Neck Dissection Is Associated with Decreased Survival Regardless of T Staging and Administration of Radioactive Iodine Therapy: The First Evidence

For the rare but aggressive insular thyroid carcinoma (ITC), there's no clear evidence to determine whether prophylactic central compartment neck dissection (CCND) is necessary for cN0 disease. This study provides the first evidence that treating cN0 ITC without prophylactic CCND is associated with decreased survival regardless of T staging and administration of RAI therapy. Background. Regarding the rare but aggressive insular thyroid carcinoma (ITC), the value of prophylactic central compartment neck dissection (CCND) for clinically node-negative (cN0) disease is unclear. We aimed to provide the first evidence. Methods. N0 and pN1a ITC patients were identified from the Surveillance, Epidemiology, and End Results database. These patients were divided into thyroid-surgery + CCND group (pN0/pN1a patients confirmed by CCND) and thyroid-surgery group (cN0 patients without CCND). Differences in overall survival (OS) and disease-specific survival (DSS) between the two groups were evaluated. Subgroup analyses were also conducted. Results. Of the overall 112 patients, 44 (39.3%) received CCND. On multivariate analyses, the lobectomy ± isthmusectomy/total-thyroidectomy (Lob/TT) group demonstrated poorer OS and DSS than the Lob/TT + CCND group (P < 0.05). When we separately analyzed patients treated by TT, multivariate analyses showed the TT group still revealed compromised OS and DSS than the TT + CCND group (P < 0.05). Furthermore, absence of CCND independently predicted decreased OS no matter whether radioactive iodine (RAI) was administered. Similar results were obtained for T3/T4 patients. Moreover, for T1/T2 patients receiving CCND, 0/12 died during the study period, while for T1/T2 patients without CCND, 8/23 (34.8%) died, 5/23 (21.7%) due to ITC. Conclusion. Regardless of T staging and RAI treatment, cN0-ITC patients without CCND had decreased survival compared with pN0/pN1a patients receiving CCND. Therefore, if a cN0 patient is diagnosed with ITC, prophylactic CCND may be considered as a secondary procedure (postoperatively diagnosed) or a primary procedure (preoperatively/intraoperatively diagnosed). Prospective studies are expected to validate the conclusion.

Predictive Value of BRAFV600E Mutation for Lymph Node Metastasis in Papillary Thyroid Cancer: A Meta-analysis

BRAF^V600E mutation has been thought to be a valuable molecular marker that may predict a worse prognosis for papillary thyroid cancer (PTC). But whether BRAF^V600E mutation is associated with lymph node metastasis (LNM) remains controversial. Different surgical strategies may bring a bias in demonsstrating the association between them. In order to delineate a risk stratification to guide a tailored initial approach to tumors that express BRAF^V600E mutation, we performed this meta-analysis by using the articles in which total or near-total thyroidectomy plus bilateral central lymph node dissection was routinely performed to avoid the bias from the surgical strategy. We searched the Medline, Embase and CNKI database for eligible studies from January 2003 to May 2018. Meta-analysis was performed using the STATA 12.0 software. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated under fixed-effects or randomeffects models. Fifteen clinical studies were included with a total of 4909 PTC patients. Our meta-analysis results reported that BRAFV600E mutation was associated with LNM (OR=1.34; 95% CI: 1.09-1.65; P=0.005), as well as central LNM (OR=1.59; 95% CI: 1.35-1.88; P<0.00001). Moreover, in patients with papillary thyroid microcarcinoma, we also confirmed the predictive value of BRAF^V600E mutation for LNM (OR=3.49; 95% CI: 2.02-6.02; P<0.00001). This meta-analysis demonstrates that BRAF^V600E mutation is closely related to LNM in PTC patients. The results suggest that BRAF^V600E mutation can be considered as a risk factor for LNM in PTC. Moreover, combining BRAF^V600E mutation with other risk factors to determine the initial surgical treatment may bring benefits for PTC patients.

Functional visceral fat activity evaluated by preoperative F-18 FDG PET/CT predicts regional lymph node metastasis in differentiated thyroid cancer

OBJECTIVE

We investigated the predictive role of functional visceral fat activity evaluated by preoperative F-18 FDG PET/CT for regional lymph node metastasis in patients with differentiated thyroid cancer.

DESIGN AND PATIENTS

Fifty-eight patients with newly diagnosed differentiated thyroid cancer were enrolled in this study, retrospectively (men 14; women 44; age 53 ± 14.5). They all received preoperative F-18 FDG PET/CT and surgery. Functional visceral fat activity was defined as maximum standardized uptake value (SUVmax) of visceral fat divided by SUVmax of subcutaneous fat (V/S ratio). Pathology results were confirmed through the surgical specimens.

RESULTS

The patients with regional lymph node metastasis showed higher functional visceral fat activity (V/S ratio) than the patients without regional lymph node metastasis (2.12 ± 0.6 vs 1.62 ± 0.34, P = .001). V/S ratio of 1.78 was suggested as an optimal cut-off value for predicting regional lymph node metastasis (sensitivity; 70.3%, specificity; 83.3%, area under the curve; 0.778, P < .0001). Furthermore, functional visceral fat activity was significantly associated with regional lymph node metastasis in patients with differentiated thyroid cancer by univariate and multivariate analyses.

CONCLUSIONS

Functional visceral fat activity significantly affects the regional lymph node metastasis status in patients with differentiated thyroid cancer. Furthermore, it may also be useful to predict regional lymph node metastasis.

Optimization of the risk-benefit ratio of differentiated thyroid cancer treatment

The vast majority of differentiated thyroid cancers (DTC) are characterized by an innocuous nature, excellent patient survival, and limited treatment requirement. However, a significant proportion of affected patients is prone to receiving overtreatment, due to undertreatment concerns associated with the difficulty to differentiate them from a small minority affected by aggressive DTC. Identification of prognostic factors and development of staging systems has helped to reduce the proportion of overtreatment in DTC. However, the absolute number of overtreated patients continues to increase, as a result of an on-going incidence surge in early DTC associated with the increased application and sensitivity of modern diagnostic tools. In the present paper, we describe how DTC treatment can be optimized by thoughtful evidence-based balancing of oncologic safety against treatment associated morbidity.

Primary leiomyosarcoma of thyroid gland: the youngest case

Primary leiomyosarcomas of the thyroid gland are extremely rare. We report a case of a 32 year-old women with a multinodular goiter. She underwent total thyroidectomy. The tumor histology showed spindle-shaped cells that expressed desmine, caldesmone and smooth muscle actine but were negative cytokeratins.

Surgical treatment of thyroid follicular neoplasms: results of a retrospective analysis of a large clinical series

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN), considering their low definitive malignancy rate and the limited predictive power of preoperative clinic-diagnostic factors, is still controversial. On behalf of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB), we collected and analyzed the experience of 26 endocrine centers by computerized questionnaire. 1379 patients, surgically treated after a FN diagnosis from January 2012 and December 2103, were evaluated. Histological features, surgical complications, and medium-term outcomes were reported. Total thyroidectomy (TT) was performed in 1055/1379 patients (76.5 %), while hemithyroidectomy (HT) was carried out in 324/1379 cases (23.5 %). Malignancy rate was higher in TT than in HT groups (36.4 vs. 26.2 %), whereas the rates of transient and definitive hypoparathyroidism following TT were higher than after HT. Consensual thyroiditis (16.8 vs. 9.9 %) and patient age (50.9 vs. 47.9 %) also differed between groups. A cytological FN diagnosis was associated to a not negligible malignancy rate (469/1379 patients; 34 %), that was higher in TT than in HT groups. However, a lower morbidity rate was observed in HT, which should be considered the standard of care in solitary lesions in absence of specific risk factors. Malignancy could not be preoperatively assessed and clinical decision-making is still controversial. Further efforts should be spent to more accurately preoperatively classify FN thyroid nodules.

The prognostic value of regional lymph node metastases in patients of Guangdong Province, China with differentiated thyroid cancer: A multicenter retrospective clinical study

Although the prognostic value of nodal metastases in differentiated thyroid cancer remains controversial, it is of interest to evaluate and understand the different characteristics of predictive outcomes.A multicenter retrospective study was conducted in 215 untreated patients with differentiated thyroid cancer from July 1997 to July 2015 in 4 medical centers of Guangdong Province. A total of 107 patients with nodal metastases (group A) were compared to 108 patients without metastases (group B). The 5-year disease-free survival (DFS), overall survival (OS), and postoperative complications in both groups were calculated. Variables predictive of DFS and OS were evaluated in group A.The group A had lower 5-year DFS (69.16%, 11 months) and shorter median time of recurrence than those in group B (87.96%, 8.5 months, respectively, P < 0.001). The incidence of temporary hypoparathyroidism in group A is lower; whereas higher incidence of temporary unilateral vocal cord palsy, permanent hypoparathyroidism, permanent unilateral vocal cord palsy, and bilateral vocal cord palsy in group A were observed. Both univariate and multivariate analyses in group A revealed that age, pathological tumor node metastasis (pTNM) stage, and histology were related to DFS (P < 0.05); while pTNM stage and histology were related to OS only in univariate analyses.Positive nodal metastases have significant prognostic value in patients with differentiated thyroid cancer in Guangdong, China and primarily reduce DFS. Moreover, patients with positive nodal metastases who are >45 years and have higher pTNM stage or follicular histology tend to have poor prognosis. Selective lymph node dissection with appropriate postoperative treatment and frequent follow-up should be accorded to these vulnerable groups of patients.

Clinical significance of prophylactic central compartment neck dissection in the treatment of clinically node-negative papillary thyroid cancer patients

Background

Lymph nodal involvement is very common in differentiated thyroid cancer, and in addition, cervical lymph node micrometastases are observed in up to 80 % of papillary thyroid cancers. During the last decades, the role of routine central lymph node dissection (RCLD) in the treatment of papillary thyroid cancer (PTC) has been an object of research, and it is now still controversial. Nevertheless, many scientific societies and referral authors have definitely stated that even if in expert hands, RCLD is not associated to higher morbidity; it should be indicated only in selected cases.

Main body

In order to better analyze the current role of prophylactic neck dissection in the surgical treatment of papillary thyroid cancers, an analysis of the most recent literature data was performed. Prophylactic or therapeutic lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, and papillary thyroid cancer were used by the authors as keywords performing a PubMed database research. Literature reviews, PTCs large clinical series and the most recent guidelines of different referral endocrine societies, inhering neck dissection for papillary thyroid cancers, were also specifically evaluated. A higher PTC incidence was nowadays reported in differentiated thyroid cancer (DTC) clinical series. In addition, ultrasound guided fine-needle aspiration citology allowed a more precocious diagnosis in the early phases of disease. The role of prophylactic neck dissection in papillary thyroid cancer management remains controversial especially regarding indications, approach, and surgical extension. Even if morbidity rates seem to be similar to those reported after total thyroidectomy alone, RCLD impact on local recurrence and long-term survival is still a matter of research. Nevertheless, only a selective use in high-risk cases is supported by more and more scientific data.

Conclusions

In the last years, higher papillary thyroid cancer incidence and more precocious diagnoses were worldwide reported. Among endocrine and neck surgeons, there is agreement about indications to prophylactic treatment of node-negative “high-risk” patients. A recent trend toward RCLD avoiding radioactive treatment is still debated, but nevertheless, prophylactic dissections in low-risk cases should be avoided. Prospective randomized trials are needed to evaluate the benefits of different approaches and allow to drawn definitive conclusions.

Endoscopic thyroidectomy along with bilateral central neck dissection (ETBC) increases the risk of transient hypoparathyroidism for patients with thyroid carcinoma

Increasing number of patients with thyroid carcinoma, especially young female patients, prefer to choose endoscopic thyroidectomy with bilateral central neck dissection (ETBC) for perfect cosmetic effects. However, the incidence of hypoparathyroidism after ETBC has not been well studied. Ninety six patients with papillary thyroid carcinoma were enrolled. All patients, including 49 ETBC and 47 open surgery patients, underwent total thyroidectomy with bilateral central neck dissection (CND). Some patients also underwent lateral neck dissection simultaneously. The incidence of hypoparathyroidism and parathyroid hormone (PTH) level were examined. Patients in the open surgery group had more advanced lesions, with larger tumor (p = 0.000), older age (p = 0.000), and more serious local involvement. The dissection extent of the open group was significantly larger than that of the ETBC group (p = 0.006). In contrast, the ETBC group with less dissection extent showed a significantly higher incidence of transient hypoparathyroidism than the open group (59.2 vs. 29.6 %, p = 0.004). The average PTH decline of the ETBC group was significantly higher than that of the open group on postoperative day 1 (POD1) (32.1 vs. 21.6 pg/ml, p = 0.010). Furthermore, the ETBC group had a significantly higher portion of patients with a PTH <10 pg/ml on POD1 (p = 0.001). One patient in the ETBC group developed permanent hypoparathyroidism. Autotransplantation and inadvertent removal rates of parathyroid did not differ between the two groups. Although generally considered a safe method for patients with thyroid carcinoma, ETBC may increase the risk of transient hypoparathyroidism compared with conventional open surgery.

Role of prophylactic central compartment lymph node dissection in clinically N0 differentiated thyroid cancer patients: analysis of risk factors and review of modern trends

In the last years, especially thanks to a large diffusion of ultrasound-guided FNBs, a surprising increased incidence of differentiated thyroid cancer (DTC), "small" tumors and microcarcinomas have been reported in the international series. This led endocrinologists and surgeons to search for "tailored" and "less aggressive" therapeutic protocols avoiding risky morbidity and useless "overtreatment". Considering the most recent guidelines of referral endocrine societies, we analyzed the role of routine or so-called prophylactic central compartment lymph node dissection (RCLD), also considering its benefits and risks. Literature data showed that the debate is still open and the surgeons are divided between proponents and opponents of its use. Even if lymph node metastases are commonly observed, and in up to 90% of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is subject to intensive research and the best indications of lymph node dissection are still controversial. Identification of prognostic factors for central compartment metastases could assist surgeons in determining whether to perform RLCD. Considering available evidence, a general agreement to definitely reserve RCLD to "high-risk" cases was observed. More clinical researches, in order to identify risk factors of meaningful predictive power and prospective long-term randomized trials, should be useful to validate this selective approach.

Value of additional von Kossa staining in thyroid nodules with echogenic spots on ultrasound

PURPOSE

To evaluate the clinical value of additional von Kossa staining on cytology in thyroid nodules with echogenic spots on ultrasound (US).

MATERIALS AND METHODS

342 thyroid nodules were analyzed for cytology and von Kossa staining was performed to detect microcalcifications. We compared diagnostic performances and accuracies of FNA and FNA with von Kossa staining to detect malignancy. We evaluated associations of aggressive pathologic features and von Kossa positivity in the surgically confirmed papillary thyroid carcinoma (PTC) group.

RESULTS

Two hundred and thirty two (67.8%) nodules were malignant and 110 (32.2%) were benign on cytopathology. Compared to cytology alone, additional von Kossa staining slightly improved sensitivity from 89.7% to 90.9% (P=0.081). In 207 cases of surgically confirmed PTC, von Kossa positivity was an independent predictor of central lymph node metastasis in PTCs by multivariate analysis (odds ratio, 2.218; P=0.021).

CONCLUSIONS

Adding von Kossa staining to cytology improved the sensitivity of thyroid nodules with echogenic spots on US. Positive von Kossa stains in PTCs may also be useful in predicting central lymph node metastasis.

Differentiated thyroid cancer: feasibility of loboisthmectomy in an endemic region

AIM

The aim of the present retrospective study was to assess the feasibility of loboisthmectomy for the treatment of differentiated thyroid cancer in a endemic area, evaluating the histopathological features and the results of a case series of 1154 patients.

PATIENTS AND METHODS

The clinical records of 1154 patients submitted to total thyroidectomy in our Department were retrospectively reviewed to analyze the histopathological characters and the results.

RESULTS

In 1044 cases (90.5%) a papillary cancer was observed, in 110 (9.5%) a follicular carcinoma; microcarcinomas were 399 (34.5%). Multifocality was present in 323 cases (28%), in 142 unilateral (12.3%) and in 181 bilateral (15.7%). Thyroiditis coexisted in 472 patients (40.9%), multinodular goiter in 404 (35%), Graves' disease in 48 (4.1%), and multinodular toxic goiter in 38 (3.3%). Complications were: postoperative bleeding in 20 patients (1.7%), transient unilateral vocal cord paralysis in 20 (1.7%) definitive in 10 (0.86%), a transient bilateral paralysis in 1 (0.08%), a transient hypoparathyroidism in 351 (30.4%), and a definitive in 24 (2.07%). Nodal recurrence occurred in 25 patients (2.16%).

CONCLUSIONS

Total thyroidectomy remains the safest treatment in differentiated thyroid cancer, especially if performed in high volume centers in which complications can be minimized. Loboisthmectomy can be a viable and safe alternative in small (< 1 cm) unifocal tumors in patients at low risk. Loboisthmectomy is limited in endemic areas by the association with other thyroid diseases. A correct and detailed information of the patient is essential before planning surgery.

Effectiveness of an advanced hemostatic pad combined with harmonic scalpel in thyroid surgery. A prospective study

INTRODUCTION

Hemostasis during thyroidectomy is essential; however the most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with the combination of harmonic scalpel (HS) and an advanced hemostatic pad (Hemopatch).

METHODS

Patient undergone TT were divided into two groups: HS + hemopatch and HS + traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates.

RESULTS

Between September 2014 and March 2015, 60 patients were enrolled (30 to Hs + Hemopatch, 30 to Hs and standard hemostasis); 71.4% female; mean age 48.5 years. The 24-h drain output was lower in the HS + hemopatch group compared with standard TT. HS and hemopatch also had a shorter mean surgery time (p < 0.0001) vs standard TT.

CONCLUSION

combination of hemopatch plus HS is effective and safe for TT with a complementary hemostatic approach.

Bilateral benign multinodular goiter: What is the adequate surgical therapy? A review of literature

BACKGROUND

Benign multinodular goiter (BMNG) is the most common endocrine disease requiring surgery. During the last few years a more aggressive approach has become the trend for bilateral BMNG treatment.

METHOD

Randomized clinical trials of any size that compared bilateral subtotal resection, Dunhill procedure and total thyroidectomy for benign multinodular goiter, published between January 2000 and the end of March 2015, were reviewed.

DISCUSSION

Total thyroidectomy can be considered the most reliable approach in preventing recurrence. The Dunhill procedure is related to a higher rate of recurrence, but rarely recurrences after Dunhill procedure lead to reoperation. Total thyroidectomy avoid completion thyroidectomy for incidental carcinoma and its related risks. Recurrent laryngeal nerve (RLN) palsy becomes less common as surgical experience increases. Transient and permanent hypoparathyroidism is strictly related to the extent of neck dissection. In the risk-cost analysis we must consider the type of patient candidated to surgery and the impact of the surgical protocol we apply. When thyroid surgery is taken in consideration, specific complication rates of different procedures in each hospital must be analyzed accordingly to patient-specific risk factors and local expertise.

CONCLUSION

The Dunhill procedure seems to be a good compromise between radicality and prevention of complications, avoiding reoperation for recurrence or completion thyroidectomy for incidental thyroid carcinoma. More follow-up studies and prospective studies are necessary to better evaluate, definitively, whether to prefer total thyroidectomy or Dunhill procedure in case of benign goiter surgery.

Surgical morbidity of cervical lymphadenectomy for thyroid cancer: A retrospective cohort study over 25 years

INTRODUCTION

Prognosis of thyroid cancer is strictly related to loco-regional metastases. Cervical lymphadenectomy has a specific oncologic role but may lead to significant increase of morbidity. Aim of the study is the analysis of surgical morbidity in cervical lymphadenectomy for thyroid cancer.

METHODS

We retrospectively analyzed 1.765 thyroid cancers operated over a period of 25 years at S. Maria University Hospital, Terni, University of Perugia, Italy. Type of lymphadenectomy, histology and complications were analysed.

RESULTS

A prevalence of differentiated and medullary cancers was observed (respectively 88% and 7.2%). Central lymphadenectomy was carried out in 425 patients, lateral modified and radical lymphadenectomy respectively in 651 and 17 cases. Following central neck dissection we observed: bilateral and unilateral temporary recurrent nerves palsy respectively of 0.7% and 3.5%, unilateral permanent palsy in 1.6% of cases, temporary and permanent hypoparathyroidism respectively in 17.6% and 4.4%. After lateral neck dissection we observed: intra and post-operative haemorrhage respectively in 2% and 0.29%, respiratory distress in 0.29%, lesions of facial nerve in 0.44%, of vagus in 0.14%, of phrenic nerve in 0.14%, of hypoglossal nerve in 0.29%, of the accessory nerve, transient in 1.34% and permanent in 0.29%, permanent lesion of cervical plexus in 0.29%, salivary fistula in 0.14% and chylous fistula in 1.04% of patients. Student's t test was used to compare groups when appliable.

CONCLUSION

Central and lateral cervical lymph node dissection are associated to severe morbidity. Correct indication, surgical expertise, high volume of patients and early multidisciplinary management of complications is the key of an acceptable balance between oncologic benefits and surgical morbidity.

A Gelatin-Thrombin Matrix Topical Hemostatic Agent (Floseal) in Combination With Harmonic Scalpel Is Effective in Patients Undergoing Total Thyroidectomy: A Prospective, Multicenter, Single-Blind, Randomized Controlled Trial

BACKGROUND

Hemostasis during thyroidectomy is essential; however, the safest, most efficient, and most cost-effective way to achieve this is unclear. This randomized, multicenter, single-blind, prospective study evaluated the efficacy and safety of using different hemostatic approaches in patients undergoing total thyroidectomy.

METHODS

Patients aged ≥18 to 70 years were randomized to Floseal + a harmonic scalpel (HS), Floseal alone, HS alone, or standard total thyroidectomy. Primary endpoint was 24-hour drain output. Secondary endpoints included surgery duration and complications.

RESULTS

Two hundred and six patients were randomized to Floseal + HS (n = 52), Floseal alone (n = 54), HS alone (n = 50), and standard total thyroidectomy (n = 50). The 24-hour drain output was lower in the Floseal + HS group compared with standard thyroidectomy. Floseal + HS also had a shorter surgery time (P < .0001) versus the other 3 treatments.

CONCLUSION

Floseal + HS can be effective at reducing postsurgical drain output and provides a complementary hemostatic approach in patients undergoing total thyroidectomy.

Intraoperative ultrasonography is useful in surgical management of neck metastases in differentiated thyroid cancers

Differentiated thyroid carcinomas are the most common malignancies of endocrine organs. Metastases to cervical lymph nodes occur in 20-50% of cases. Recurrence and survival rates are closely related to the type of surgery performed. High-resolution ultrasonography (USG) is a sensitive imaging method used to detect occult lymph node metastases in patients with thyroid cancer. We evaluated how intraoperative USG affected surgical success. This was a retrospective study comparing two groups of patients with thyroid carcinoma who underwent cervical lymph node dissection. A total of 101 patients (33 males and 68 females) were included. Group 1 included 53 patients who underwent surgery with intraoperative USG guidance. Group 2 included 48 patients who underwent surgery without the use of USG. All patients were followed up (mean 23 months; range 5-44 months) with thyroglobulin measurements and USG evaluations. Group 1 (intraoperative USG) had a residual/recurrent tumor rate of 1.9% (1/53 patients). Group 2 had a residual/recurrent tumor rate of 12.5% (6/48 patients). A statistically significant difference appeared between the residual/recurrent tumor rates in Groups 1 and 2 (p<0.05). In addition to its classical use in diagnosis and follow-up, intraoperative use of high-resolution USG can improve surgical success and may decrease the number of residual/recurrent tumors encountered during follow-up.

Comparative effectiveness in thyroid cancer: key questions and how to answer them

Controversies in treatment of thyroid cancer remain despite numerous published studies. Robust comparative effectiveness studies examining: (1) the role of prophylactic central compartment neck dissection (pCCND) in patients with papillary thyroid cancer (PTC); (2) the use of post-operative radioactive iodine (RAI) ablation therapy following total thyroidectomy; (3) use of low versus high doses of I-131 in RAI therapy; (4) thyroid hormone withdrawal (THW) versus recombinant thyroid stimulating hormone (rhTSH) prior to RAI; and (5) the role of routine measurement of serum calcitonin levels are needed to help strengthen existing treatment recommendations. Reasons for the controversies and suggestions for quality comparative effectiveness studies are discussed.

Autotransplantation of Inferior Parathyroid glands during central neck dissection for papillary thyroid carcinoma: a retrospective cohort study

INTRODUCTION

The management of inferior parathyroid glands during central neck dissection (CND) for papillary thyroid carcinoma (PTC) remains controversial. Most surgeons preserve inferior parathyroid glands in situ. Autotransplantation is not routinely performed unless devascularization or inadvertent parathyroidectomy occurs. This retrospective study aimed to compare the incidence of postoperative hypoparathyroidism and central neck lymph node (CNLN) recurrence in patients with PTC who underwent inferior parathyroid glands autotransplantation vs preservation in situ.

METHODS

This is a retrospective study which was conducted in a tertiary referral hospital. A total of 477 patients with PTC (pN1) who underwent total thyroidectomy (TT) and bilateral CND with/without lateral neck dissection were included. Patients' demographical characteristics, tumor stage, incidence of hypoparathyroidism, CNLN recurrence and the number of resected CNLN were analyzed.

RESULTS

Three hundred and twenty-one patients underwent inferior parathyroid glands autotransplantation (autotransplantation group). Inferior parathyroid glands were preserved in situ among 156 patients (preservation group). Permanent hypoparathyroidism rate was 0.9% (3/321) versus 3.8% (6/156) respectively (p = 0.028). Mean numbers of resected CNLN were 15 ± 3 (6-23) (autotransplantation group) versus 11 ± 3 (7-21) (preservation group) (p < 0.001). CNLN recurrence rate was 0.3% (1/321) versus 3.8% (6/156) respectively (p = 0.003).

CONCLUSION

Inferior parathyroid glands autotransplantation during CND of PTC (pN1) might reduce permanent hypoparathyroidism and CNLN recurrence. Further study enrolling more patients with long-term follow-up is needed to support this conclusion.

The role of surgery in the current management of differentiated thyroid cancer

In the last decades, a surprising increased incidence of differentiated thyroid cancer (DTC), along with a precocious diagnosis of "small" tumors and microcarcinomas have been observed. In these cases, better oncological outcomes are expected, and a "tailored" and "less aggressive" multimodal therapeutic protocol should be considered, avoiding an unfavorable even if minimal morbidity following an "overtreatment." In order to better define the most suitable surgical approach, its benefits and risks, we discuss the role of surgery in the current management of DTCs in the light of data appeared in the literature. Even if lymph node metastases are commonly observed, and in up to 90 % of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is still argument of intensive research, and indications and extension of lymph node dissection (LD) are still under debate. In particular, endocrine and neck surgeons are still divided between proponents and opponents of routine central LD (RCLD). Considering the available evidence, there is agreement about total thyroidectomy, therapeutic LD in clinically node-positive DTC patients, and RCLD in "high risk" cases. Nevertheless, indications to the best surgical treatment of clinically node-negative "low risk" patients are still subject of research. Considering on the one hand, the recent trend toward routine central lymphadenectomy, avoiding radioactive treatment, and on the other hand, the satisfactory results obtained reserving prophylactic LD to "high risk" patients, we think that further prospective randomized trials are needed to evaluate the best choice between the different surgical approaches.

Hypocalcemia following thyroid surgery: incidence and risk factors. A longitudinal multicenter study comprising 2,631 patients

Postoperative hypocalcemia is the most frequent complication of total thyroidectomy. It may have a delayed onset, and therefore delays the discharge from the hospital, requiring calcium replacement therapy to alleviate clinical symptoms. During a 7-month period, 2,631 consecutive patients undergoing primary or completion thyroidectomy were prospectively followed up and underwent analysis regarding postoperative hypoparathyroidism. Data were prospectively collected by questionnaires from 39 Italian endocrine surgery units affiliated to the Italian Endocrine Surgery Units Association (Club delle Unità di EndocrinoChirurgia-UEC), where thyroid surgery is routinely performed. The incidence of hypoparathyroidism was 28.8 % (757 patients), including transient hypocalcemia (27.9 %-734 patients) and permanent hypocalcemia (0.9 %-23 patients). The rate of asymptomatic hypocalcemia was 70.80 %. The incidence of permanent hypocalcemia was higher in the symptomatic hypocalcemia group (7.5 %) than in asymptomatic one (1.5 %). Female patients experienced a transient postoperative hypocalcemia more frequently than male patients (29.7 and 21.2 %, respectively; p < 0.0001). The percentage developing hypocalcemia in patients in which parathyroid glands were intraoperatively identified and preserved was higher than in the patients in which the identification of parathyroid glands was not achieved (29.2 vs. 18.7 %, p < 0.01). This prospective study confirmed the main risk factors for postoperative hypocalcemia: thyroid cancer, nodal dissection, and female gender. It farther showed that identifying parathyroids has an important role to prevent permanent hypocalcemia though with a higher risk of transient hypocalcemia. A suitable informed consent should especially emphasize the importance of some primary factors in increasing the risk of hypocalcemia after thyroid surgery.

Can increased tumoral vascularity be a quantitative predicting factor of lymph node metastasis in papillary thyroid microcarcinoma?

The aim of the present study was to evaluate the clinical implications of the vascular index (VI) as a predicting factor for central and lateral lymph node metastasis (LNM) in patients with papillary thyroid microcarcinoma (PTMC). From January 2011 to October 2011, 588 patients (495 females, 93 males) who were diagnosed with PTMC were included. Clinicopathologic characteristics of patients and ultrasound (US) features of the lesions including VI were evaluated retrospectively. The VI was measured with QLAB 7.0 quantification software using preoperative Doppler US images. Univariate and multivariate analysis were used to assess predictive factors of LNM. From 588 patients, 140 patients (23.8 %) had central LNM and 26 patients (4.4 %) had lateral LNM on pathologic results. The presence of lateral LNM [odds ratio (OR) 5.46; 95 % confidence interval (CI) = 2.19-13.64], bilaterality (OR 2.16; 95 % CI 1.17-4.01), and increased tumor size (OR 1.15; 95 % CI 1.04-1.28) were significant independent factors for predicting central LNM. The presence of central LNM (OR 5.58; 95 % CI 2.22-14.04), upper third location of malignancy (OR 2.50; 95 % CI 1.01-6.21), and tumor size (OR 1.34; 95 % CI 1.03-1.73) were significant independent factors for predicting lateral LNM. However, the VI was not a significant predicting factor for both central and lateral LNM. Therefore, the VI of PTMC may not be useful for predicting central and lateral LNM in patients with PTMC.

Central compartment lymph node dissection for differentiated thyroid cancer: review of the literature

Central lymph node dissection (CLND) remains an important component of the surgical treatment of differentiated thyroid cancer. The indication for CLND is the presence of image-positive metastases in level VI lymph nodes; the elective dissection of radiographically normal central compartment lymph nodes in patients with differentiated thyroid cancer remains controversial. The different types of CLND will be discussed herein, and some of the surrounding controversies will be highlighted.

Identification alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients

BACKGROUND

The aim of this study was to evaluate the ability of intraoperative neuromonitoring in reducing the postoperative recurrent laryngeal nerve palsy rate by a comparison between patients submitted to thyroidectomy with intraoperative neuromonitoring and with routine identification alone.

METHODS

Between June 2007 and December 2012, 2034 consecutive patients underwent thyroidectomy by a single surgical team. We compared patients who have had neuromonitoring and patients who have undergone surgery with nerve visualization alone. Patients in which neuromonitoring was not utilized (Group A) were 993, patients in which was utilized (group B) were 1041.

RESULTS

In group A 28 recurrent laryngeal nerve injuries were observed (2.82%), 21 (2.11%) transient and 7 (0.7%) permanent. In group B 23 recurrent laryngeal nerve injuries were observed (2.21%), in 17 cases (1.63%) transient and in 6 (0.58%) permanent. Differences were not statistically significative.

CONCLUSIONS

Visual nerve identification remains the gold standard of recurrent laryngeal nerve management in thyroid surgery. Neuromonitoring helps to identify the nerve, in particular in difficult cases, but it did not decrease nerve injuries compared with visualization alone. Future studies are warranted to evaluate the benefit of intraoperative neuromonitoring in thyroidectomy, especially in conditions in which the recurrent nerve is at high risk of injury.

Long-term function of parathyroid subcutaneous autoimplantation after presumed total parathyroidectomy in the treatment of secondary hyperparathyroidism. A clinical retrospective study

INTRODUCTION

Parathyroidectomy (PTx) is recommended in patients affected by secondary hyperparathyroidism (2HPT) of chronic kidney disease-mineral bone disorders (CKD-MBD), resistant to medical treatment. Analyzing total parathyroidectomy with muscular or subcutaneous autoimplantation (TPai) outcomes in hemodialysis (HD) 2HPT patients, and monitoring intact parathyroid hormone (iPTH) levels, we evaluated long-term functional results of subcutaneous parathyroid glandular tissue autoimplantation.

METHODS

40 HD 2HPT patients, resistant to medical treatment, and awaiting for renal transplantation, underwent total parathyroidectomy with subcutaneous autoimplantation of 9-12 fragments of not nodular hyperplasia parathyroid tissue in not dominant forearm. iPTH were analyzed 24 h, and 3-6-12-24 months after surgery. The 1.08-6.99 pmol/L range was taken as reference of normal iPTH level based on which eu- (1.08-6.99), hypo- (<1.08), aparathyroidism (0) and persistence or relapse (>6.99) of disease were determined.

RESULTS

In every case PTai determined an extraordinary improvement of quality of life, associated with a notable reduction of iPTH serum level. Immediate normalization of iPTH was achieved in 50% of cases; hypoparathyroidism in 25% of cases and persistence of disease in 25% were observed. Long term follow-up showed a reduction of hypoparathyroidism and an increase of relapse rate up to 20%. Grafting resection was never performed.

DISCUSSION

Subcutaneous autotrasplantation is a very simple and fast surgical technique. Nevertheless, similar success and recurrence rates were reported following muscular or subcutaneous grafting, as confirmed in our experience.

CONCLUSIONS

Subcutaneous grafting was effective as muscular implantation, with comparable functional results, but avoiding its potential complications.

Efficacy of combined treatment for anaplastic thyroid carcinoma: results of a multinstitutional retrospective analysis

INTRODUCTION

Anaplastic thyroid carcinoma (ATC) is a killer tumor, characterized by local invasiveness, risk of recurrence and very poor prognosis. Due to its rarity, clinical case studies concerning management are lacking.

METHODS

We retrospectively reviewed a multinstitutional clinical series of 114 consecutive patients treated between 1996 and 2012 for ATC. The outcomes of a combined treatment were analyzed considering the impact of surgery and radiotherapy on survival.

RESULTS

Patients were divided in groups A and B considering tumor size (tumor lesser and larger than 5 cm). Surgery was carried out in 71 patients, radiotherapy in 89 patients. Tracheostomy and endoprothesis were used respectively in 48.7% and in 25.6% of patients. The mean survival was 5.35 (±3.2) months with no significant difference in group A vs group B. A better survival was observed in both groups of patients undergone a surgical treatment compared to no treated patients (p = 0.001 and p = 0.0001) or to patients undergone radiotherapy alone (p = 0.047 and p = 0.0001). Combination of surgery and radiotherapy significantly improved outcome (p = 0.017).

DISCUSSION

Despite disappointing results from single therapeutic approach, multimodal strategy has progressively become the treatment of choice in ATC, with surgery being the cornerstone of the management.

CONCLUSION

Although dismal prognosis, the combined treatment might significantly improves locoregional disease control, achieving acceptable survival in selected patients and adequate palliation of the symptoms.

Clinicopathological pattern of lymph node recurrence of papillary thyroid cancer. Implications for surgery

INTRODUCTION

Lymph nodal involvement in papillary thyroid cancers is very common, but the role of lymph node dissection is still controversial. Surgeons are consequently divided between opposed to and in favor of routine central neck dissection associated with total thyroidectomy.

METHODS

Clinical records of 210 patients undergoing from January 2000 to December 2006 total thyroidectomy without routine lymph node dissection were retrospectively evaluated. One hundred and ninety eight patients (94.2%) underwent radioiodine ablation as well, followed by Thyroid Stimulating Hormone suppression therapy. In patients with loco regional lymph nodal recurrence, central (VI) and ipsilateral (III-IV) lymph node dissection was performed.

RESULTS

Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent vocal fold paralysis were respectively 1.4% and 1.9%. After an 8-year mean follow-up, the rate of loco regional recurrence was 4.2%-9/210 patients. In these cases selective lymph node dissection was carried out without complications.

DISCUSSION

The role of neck dissection in papillary thyroid cancer management, is still subject of research and controversial regarding routine or therapeutic indications, surgical extension, its impact on local recurrence and survival.

CONCLUSION

A low loco regional recurrence rate may be observed after total thyroidectomy without prophylactic lymph node dissection. Lymph nodal recurrences were more frequent in young male patients, sometime affected by follicular variant, in each case less than 2 cm. There is a general agreement about the extension of therapeutic lymph node dissection, while routine central neck dissection is still controversial and may be indicated in high risk patients.

Controversies in the surgical management of thyroid follicular neoplasms. Retrospective analysis of 721 patients

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions, is still controversial. Analysing and comparing the experience of two units for endocrine surgery, we retrospectively evaluated 721 patients, surgically treated after a follicular neoplasm diagnosis. Total thyroidectomy was routinely performed in one Institution, while in the other one it was selectively carried out. The main criteria leading to hemythyroidectomy were a single nodule, the age ≤45 years, the absence of thyroiditis or clinical/intraoperative suspicion of malignancy. Total thyroidectomy was performed in 402/721 patients (55.7%), hemythyroidectomy in 319/721 cases (44.2%) and a completion thyroidectomy in 51/319 cases (15.9%). The overall malignancy rate was 24% (176/721 patients), respectively 16% (51/319 patients) following hemythyroidectomy, and 31% (125/402 patients) following total thyroidectomy. Definitive recurrent laryngeal nerve paralysis and permanent hypoparathyroidism were not reported in hemythyroidectomy patients in which lower mean hospitalization and costs were observed. Considering the low-risk of follicular neoplasm solitary lesions, hemythyroidectomy is still the safest standard of care with lower hospitalization and costs. In case of multiglandular disease or thyroiditis, that might be associated with a higher risk of cancer, total thyroidectomy should be recommended. Further investigation is warranted to achieve a better preoperative follicular neoplasm diagnostic accuracy in order to reduce the amount of unnecessary surgical operations with a diagnostic aim.

Total thyroidectomy without prophylactic central neck dissection in clinically node-negative papillary thyroid cancer: is it an adequate treatment?

Background

Cervical lymph node metastases in papillary thyroid cancer are common. Although central neck dissection is indicated in clinically nodal-positive disease, it remains controversial in patients with no clinical evidence of nodal metastasis. The aim of this retrospective study was to determine the outcomes of clinically lymph node-negative patients with papillary thyroid cancer who underwent total thyroidectomy without a central neck dissection, in order to determine the rates of recurrence and reoperation in these patients compared with a group of patients submitted to total thyroidectomy with central neck dissection.

Methods

Two-hundred and eighty-five patients undergoing total thyroidectomy with preoperative diagnosis of papillary thyroid cancer, in the absence of suspicious nodes, were divided in two groups: those who underwent a thyroidectomy only (group A; n = 220) and those who also received a central neck dissection (group B; n = 65).

Results

Six cases (2.1%) of nodal recurrence were observed: 4 in group A and 2 in group B. Tumor histology was associated with risk of recurrence: Hürthle cell-variant and tall cell-variant carcinomas were associated with a high risk of recurrence. Multifocality and extrathyroidal invasion also presented a higher risk, while smaller tumors were at lower risk.

Conclusions

The role of prophylactic central lymph node dissection in the management of papillary thyroid cancer remains controversial. Total thyroidectomy appears to be an adequate treatment for clinically node-negative papillary thyroid cancer. Prophylactic central neck dissection could be considered for the more appropriate selection of patients for radioiodine treatment and should be reserved for high-risk patients only. No clinical or pathological factors are able to predict with any certainty the presence of nodal metastasis. In our experience, tumor size, some histological types, multifocality, and locoregional infiltration are related to an increased risk of recurrence. The potential use of molecular markers will hopefully offer a further strategy to stratify the risk of recurrence in patients with papillary thyroid cancer and allow a more tailored approach to offer prophylactic central neck dissection to patients with the greatest benefit. Multi-institutional larger studies with longer follow-up periods are necessary to draw definitive conclusions.

Follicular nodules (Thy3) of the thyroid: is total thyroidectomy the best option?

Background

Identification of the best management strategy for nodules with Thy3 cytology presents particular problems for clinicians. This study investigates the ability of clinical, cytological and sonographic data to predict malignancy in indeterminate nodules with the scope of determining the need for total thyroidectomy in these patients.

Methods

The study population consisted of 249 cases presenting indeterminate nodules (Thy3): 198 females (79.5%) and 51 males (20.5%) with a mean age of 52.43 ± 13.68 years. All patients underwent total thyroidectomy.

Results

Malignancy was diagnosed in 87/249 patients (34.9%); thyroiditis co-existed in 119/249 cases (47.79%) and was associated with cancer in 40 cases (40/87; 45.98%). Of the sonographic characteristics, only echogenicity and the presence of irregular margins were identified as being statistically significant predictors of malignancy. 52/162 benign lesions (32.1%) and 54/87 malignant were hypoechoic (62.07%); irregular margins were present in 13/162 benign lesions (8.02%), and in 60/87 malignant lesions (68.97%). None of the clinical or cytological features, on the other hand, including age, gender, nodule size, the presence of microcalcifications or type 3 vascularization, were significantly associated with malignancy.

Conclusions

The rate of malignancy in cytologically indeterminate lesions was high in the present study sample compared to other reported rates, and in a significant number of cases Hashimoto’s thyroiditis was also detected. Thus, considering the fact that clinical and cytological features were found to be inaccurate predictors of malignancy, it is our opinion that surgery should always be recommended. Moreover, total thyroidectomy is advisable, being the most suitable procedure in cases of multiple lesions, hyperplastic nodular goiter, or thyroiditis; the high incidence of malignancy and the unreliability of intraoperative frozen section examination also support this preference for total over hemi-thyroidectomy.

Impact of prophylactic central compartment neck dissection on locoregional recurrence of differentiated thyroid cancer in clinically node-negative patients: a retrospective study of a large clinical series

BACKGROUND

In clinically node-negative patients with differentiated thyroid cancer (DTC), indications for routine central lymph node dissection (RCLD) are the subject of intensive research, and surgeons are divided between the pros and cons of this surgery. To better define the role of neck dissection in the treatment of DTC, we analyzed retrospectively the results in three centers in Italy.

METHODS

The clinical records of 752 clinically node-negative patients with DTC who underwent operative treatment between January 1998 and December 2005 in three endocrine surgery referral units were evaluated retrospectively. The complications and medium- and long-term outcomes of total thyroidectomy (TT) alone (performed in 390 patients: group A) and TT combined with bilateral RCLD (362 patients: group B) were analyzed and compared.

RESULTS

The incidence of permanent hypoparathyroidism and permanent unilateral vocal folds was 1% and 0.8% in group A and 3.6% and 1.7% in the group B, respectively. Bilateral temporary recurrent nerve palsy was observed in one of the 362 patients in group B. After a follow-up of 9.5 ± 3.5 years (mean ± SD), the locoregional recurrence rate with positive cervical lymph nodes was not substantially significantly different between the two groups.

CONCLUSION

In our series, TT combined with bilateral RCLD was associated with a greater rate of transient and permanent complications. Similar incidences of locoregional recurrence were reported in the two groups of patients. Considering the recent trend toward routine central lymphadenectomy, further studies are needed to evaluate the benefits of these different approaches.

Leiomyosarcoma of the thyroid gland: A case report and literature review

Primary smooth muscle tumors of the thyroid gland are extremely rare neoplasms. Due to their rarity, clinical case studies concerning management are lacking. According to a literature review, only 19 cases of primary thyroid leiomyosarcomas (TLs) have been reported. In the majority of patients, the prognosis is poor since adjuvant radiochemotherapy is ineffective on local recurrence and on long-term survival. In this study, we report the case of a 77-year-old male affected by a rapidly enlarging mass of the anterior neck, associated with bilateral lung metastases, and increasing dysphagia and dyspnea during the previous 6 months. A Tir4 neoplasm fine needle cytological diagnosis of the right thyroid lobe was reached and the patient underwent total thyroidectomy (TT). Definitive histological examination identified a TL. The patient succumbed 40 days later due to respiratory distress. A literature review was performed and TL differential diagnoses, management, including alternative treatment strategies, and adjuvant therapy were analyzed. TL is an aggressive rare mesenchymal malignant tumor. Although an improved multimodal approach is often necessary, TT and neck dissection represent the treatment of choice and are often the only possible therapy. Adjuvant radiochemotherapy appears to be ineffective and a high mortality rate is observed. TL remains a fatal tumor, and innovative and more effective therapeutic strategies to improve management and outcomes are required.

Impact of parathyroidectomy on cardiovascular outcomes and survival in chronic hemodialysis patients with secondary hyperparathyroidism. A retrospective study of 50 cases prior to the calcimimetics era

BACKGROUND

In chronic hemodialysis patients with secondary hyperparathyroidism, pathological modifications of bone and mineral metabolism increase the risk of cardiovascular morbidity and mortality. Parathyroidectomy, reducing the incidence of cardiovascular events, may improve outcomes; however, its effects on long-term survival are still subject of active research.

METHODS

From January 2004 to December 2006, 30 hemodialysis patients, affected by severe and unresponsive secondary hyperparathyroidism, underwent parathyroidectomy - 15 total parathyroidectomy and 15 total parathyroidectomy + subcutaneous autoimplantation. During a 5-year follow-up, patients did not receive a renal transplantation and were evaluated for biochemical modifications and major cardiovascular events - death, cardiovascular accidents, myocardial infarction and peripheral vascular disease. Results were compared with those obtained in a control group of 20 hemodialysis patients, affected by secondary hyperparathyroidism, and refusing surgical treatment, and following medical treatment only.

RESULTS

The groups were comparable in terms of age, gender, dialysis vintage, and comorbidities. Postoperative cardiovascular events were observed in 18/30 - 54% - surgical patients and in 4/20 - 20%- medical patients, with a mortality rate respectively of 23.3% in the surgical group vs. 15% in the control group. Parathyroidectomy was not associated with a reduced risk of cardiovascular morbidity and survival rate was unaffected by surgical treatment.

CONCLUSIONS

In secondary hyperparathyroidism hemodialysis patients affected by severe cardiovascular disease, surgery did not modify cardiovascular morbidity and mortality rates. Therefore, in secondary hyperparathyroidism hemodialysis patients, resistant to medical treatment, only an early indication to calcimimetics, or surgery, in the initial stage of chronic kidney disease - mineral bone disorders, may offer a higher long-term survival. Further studies will be useful to clarify the role of secondary hyperparathyroidism in determining unfavorable cardiovascular outcomes and mortality in hemodialysis population.

Laparoscopic adrenal surgery: ten-year experience in a single institution

Background

Minimal invasive adrenalectomy has become the procedure of choice to treat adrenal tumors with a benign appearance, ≤ 6 cm in diameter and weighing < 100 g. Authors evaluated medium- and long-term outcomes of laparoscopic adrenalectomy (LA), performed for ten years in a single endocrine surgery unit.

Methods

We retrospectively reviewed 88 consecutive patients undergone LA for lesions of adrenal glands from 2003 to 2013. The first 30 operations were considered part of the learning curve. Doxazosin was preoperatively administered in case of pheochromocytoma (PCC), while spironolactone and potassium were employed to treat Conn's disease. Perioperative cardiovascular status modifications and surgical and medium- and long-term results were analyzed.

Results

Forty nine (55.68%) functioning tumors, and one (1.13%) bilateral adrenal disease were identified. In 2 patients (2.27%) a supposed adrenal metastasis was postoperatively confirmed, while in no patients a diagnosis of incidental primitive malignancy was performed. There was no mortality or major post operative complication. The mean operative time was higher during the learning curve. Conversion and morbidity rates were respectively 1.13% and 5.7%. Intraoperative hypertensive crises (≥180/90 mmHg) were observed in 23.5% (4/17) of PCC patients and were treated pharmacologically with no aftermath. There was no influence of age, size and operative time on the occurrence of PCC intraoperative hypertensive episodes. Surgery determined a normalization of the endocrine profile. One single PCC persistence was observed, while in a Conn's patient, just undergone right LA, a left sparing adrenalectomy was performed for a contralateral metachronous aldosteronoma.

Conclusions

LA, a safe, effective and well tolerated procedure for the treatment of adrenal neoplasms ≤ 6 cm, is feasible for larger lesions, with a similar low morbidity rate. Operative time has improved along with the increase of the experience and of the technological development. Preoperative adrenergic blockade did not prevent PCC intraoperative hypertensive crises, but facilitated the control of the hemodynamic stability.

The impact of age and oral calcium and vitamin D supplements on postoperative hypocalcemia after total thyroidectomy. A prospective study

Background

Hypocalcemia caused by transient or definitive hypoparathyroidism is the most frequent complication after total thyroidectomy (TT). We aimed to compare the impact of age and the clinical usefulness of oral calcium and vitamin D supplements on postoperative hypocalcemia after TT, and to determine which risk factors are important for hypocalcemia incidence.

Methods

Two hundred consecutive patients treated by TT were included prospectively in the present study. All patients supplemented oral calcium and vitamin D in the post-operative time. The data concerning symptomatic and laboratoristichypocalcemia were collected.

Patients were evaluated according to age, sex, postoperative serum calcium levels, and preoperative serum alkaline phosphatasis levels.

Results

Symptomatic hypocalcemia developed only in 19 patients (9.5%), whereas laboratory hypocalcemia developed in 36 patients (18%). The risk for postoperative hypocalcemia was increate 20-fold for patients older than 50 years.

Conclusions

Age is significantly associated with postoperative hypocalcemia. Implementing oral calcium and vitamin D after total thyroidectomy can reduce the incidence of hypocalcemia related to surgery.

Predictive value of nodal metastases on local recurrence in the management of differentiated thyroid cancer. Retrospective clinical study

Background

The significance of nodal metastases, very common in papillary thyroid cancer, and the role of lymph node dissection in the neoplasm management, are still controversial. The impact of lymph node involvement on local recurrence and long-term survival remains subject of active research. With the aim to better analyze the predictive value of lymph node involvement on recurrence and survival, we investigated the clinico-pathological patterns of local relapse following total thyroidectomy associated with lymph node dissection, for clinical nodal metastases papillary thyroid cancer, in order to identify the preferred surgical treatment.

Methods

Clinical records, between January 2000 and December 2006, of 69 patients undergoing total thyroidectomy associated with selective lymph node dissection for clinical nodal metastases papillary thyroid cancer, were retrospectively evaluated. Radioiodine ablation, followed by Thyroid Stimulating Hormone suppression therapy was recommended in every case. In patients with loco regional lymph nodal recurrence, a repeated lymph node dissection was carried out. The data were compared with those following total thyroidectomy not associated with lymph node dissection in 210 papillary thyroid cancer patients without lymph node involvement, at preoperative ultrasonography and intra operative inspection.

Results

Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent monolateral vocal fold paralysis were respectively 1.4 % (1/69) and 1.4% (1/69), similar to those reported after total thyroidectomy "alone". The rate of loco regional recurrence, with positive cervical lymph nodes, following 8 year follow-up, was 34.7% (24/69), higher than that reported in patients without nodal metastases (4.2%). A repeated lymph node dissection was carried out without significant complications.

Conclusions

Nodal metastases are a predictor of local recurrence, and a higher rate of lymph node involvement is expected after therapeutic lymph node dissection associated with total thyroidectomy. The prognostic significance of nodal metastases on long-term survival remains unclear, and more prospective randomized trials are requested to better evaluate the benefits of different therapeutic approaches.

Should patients with remnants from thyroid microcarcinoma really not be treated with iodine-131 ablation?

Remnant ablation by radioiodine is generally not recommended in patients presenting uni- or multifocal cancer <1 cm, in the absence of other higher risk features. We retrospectively studied low-risk patients (pts) with differentiated thyroid cancer (DTC) less than 1 cm recruited for radioiodine therapy (RAI).

METHODS

91 pts (79 women, age 48.4 ± 12 yrs) with DTC were enrolled for RAI. Patients underwent pre-therapy ultrasonography (US), those with suspected/ambiguous lymph-nodes were excluded and proposed for cytology. Treated pts underwent post-therapeutic whole body scan (WBSt) completed by neck/chest SPECT/CT, when necessary (e.g. evidence of uptake outside of thyroid bed). A target lesion on SPECT/CT was defined as an identifiable lymph-nodal site presenting a matched significant iodine uptake. The patients were followed up for 14 ± 2 months thereafter.

RESULTS

All pts/cancers were pT1. The mean histological diameter was 0.68 ± 0.23 cm. Six patients were excluded because of suspected nodal involvement at US. Thirty (35 %) out of 85 pts had suspicious WBSt as per lymph-nodal involvement which was confirmed at the subsequent SPECT/CT acquisition in most part of pts (26/30; 86 %). Overall detected target lesions was 34, and nine (26 %) had interim positive fine needle cytology.

CONCLUSIONS

a significant part of low risk DTC patients, for whom RAI is not recommended, presents an incidental suspicion of lymph-nodal involvement at WBSt confirmed by subsequent SPECT/CT. Such setting would have not been treated by I-131.

Differentiated thyroid cancer: indications and extent of central neck dissection--our experience

The aim of this retrospective study was to determine the rate of metastases in the central neck compartment and examine the morbidity and rate of recurrence in patients with differentiated thyroid cancer treated with or without a central neck dissection. Two hundred and fifteen patients undergoing total thyroidectomy with preoperative diagnosis of differentiated thyroid cancer, in the absence of suspicious nodes, were divided in two groups: those who underwent a thyroidectomy only (group A; n = 169) and those who also received a central neck dissection (group B; n = 46). Five cases (2.32%) of nodal recurrence were observed: 3 in group A and 2 in group B. Tumor histology was associated with a risk of recurrence: Hürthle cell-variant and tall cell-variant carcinomas were associated with a high risk of recurrence. Multifocality and extrathyroidal invasion also presented a higher risk, while smaller tumors were at lower risk. The results of this study suggest that prophylactic central neck dissection should be reserved for high-risk patients only. A wider use of immunocytochemical and genetic markers to improve preoperative diagnosis and the development of methods for the intraoperative identification of metastatic lymph nodes will be useful in the future for the improved selection of patients for central neck dissections.