Thyroid cancer: the case for total thyroidectomy

Retro-sternal Goitre: an Overview

Retro-sternal goitres are slow growing in nature. Dyspnoea on exertion is the most common presenting symptom due to the pressure effect of goitre on trachea. Due to the increased use of radiological investigations, retrosternal goitres are often diagnosed incidentally without any symptoms. Surgical resection is considered the gold standard management in all symptomatic patients and most of asymptomatic patients. However, "wait and watch" approach is an option, in selected asymptomatic patients, with the evolution of alternative treatment methods. So, the management of retrosternal goitre continues to be a surgical controversy. This article aims at reviewing the evidence-based practice of management of retrosternal goitres including challenges of surgery and postoperative complications.

Nanoparticles carrying fingolimod and methotrexate enables targeted induction of apoptosis and immobilization of invasive thyroid cancer

Metastatic tumors are the main cause of cancer-related death, as the invading cancer cells disrupt normal functions of distant organs and are nearly impossible to eradicate by traditional cancer therapeutics. This is of special concern when the cancer has created multiple metastases and extensive surgery would be too dangerous to execute. Therefore, combination chemotherapy is often the selected treatment form. However, drug cocktails often have severe adverse effects on healthy cells, whereby the development of targeted drug delivery could minimize side-effects of drugs and increase the efficacy of the combination therapy. In this study, we utilized the folate antagonist methotrexate (MTX) as targeting ligand conjugated onto mesoporous silica nanoparticles (MSNs) for selective eradication of folate receptor-expressing invasive thyroid cancer cells. The MSNs was subsequently loaded with the drug fingolimod (FTY720), which has previously been shown to efficiently inhibit proliferation and invasion of aggressive thyroid cancer cells. To assess the efficiency of our carrier system, comprehensive in vitro methods were employed; including flow cytometry, confocal microscopy, viability assays, invasion assay, and label-free imaging techniques. The in vitro results show that MTX-conjugated and FTY720-loaded MSNs potently attenuated both the proliferation and invasion of the cancerous thyroid cells while keeping the off-target effects in normal thyroid cells reasonably low. For a more physiologically relevant in vivo approach we utilized the chick chorioallantoic membrane (CAM) assay, showing decreased invasive behavior of the thyroid derived xenografts and an increased necrotic phenotype compared to tumors that received the free drug cocktail. Thus, the developed multidrug-loaded MSNs effectively induced apoptosis and immobilization of invasive thyroid cancer cells, and could potentially be used as a carrier system for targeted drug delivery for the treatment of diverse forms of aggressive cancers that expresses folate receptors.

Total thyroidectomy vs completion thyroidectomy for thyroid nodules with indeterminate cytology/follicular proliferation: a single-centre experience

Background

Despite total thyroidectomy (TT) is the most practiced procedure for a preoperatively diagnosed neoplastic lesion, according to the ATA guidelines, many surgeons perform completion thyroidectomy (CT) after hemithyroidectomy for patients with preoperative follicular proliferation/indeterminate cytology who are diagnosed with malignancy. CT has a higher complication rate than the primary procedure. The primary endpoint of our study is to compare the morbidity rate after CT with that after primary TT in patients with follicular proliferation/indeterminate cytology.

Methods

We retrospectively reviewed 237 patients who underwent thyroid surgery from 2009 to 2018 at our institution. We recruited only patients with follicular proliferation/indeterminate cytology and excluded those undergoing lymphadenectomies and thyroidectomies for benign pathology and staged thyroidectomies after intraoperative documentation of a RLN lesion. One hundred eighty-six of these patients underwent TT, and fifty-one underwent CT for the detection of differentiated thyroid cancer at the histological exam.

Results

No differences were found in the total complication rates between the two groups (OR 0,76, 95% CI 0.35–1.65, P = 0.49). We did not find any significant differences in the subgroup analysis. In particular, no significant differences were identified for transient hypocalcaemia (OR 1.17, 95% CI 0.44–3.11; P = 0,74), permanent hypocalcaemia (OR 1.04, 95% CI 0.21–5.18; P = 0,95), transient unilateral recurrent laryngeal nerve palsy (OR 0.78, 95% CI 0.21–2.81; P = 0,16), permanent unilateral recurrent laryngeal nerve palsy (OR 1.48, 95% CI 0.28–7.85; P = 0,61), and haematoma (OR 1,84, 95% CI 0,16-20,71; P = 0,61).

Conclusions

CT following hemithyroidectomy can be performed with acceptable morbidity in patients with thyroid nodules with preoperative indeterminate cytology/follicular proliferation.

Thyroid Cancer in Children and Adolescents

Aims and background

It was the aim of this paper to report clinical and pathologic characteristics and outcome of treatment in terms of relapse-free and overall survival in 36 patients under 20 years of age and treated for thyroid cancer at Padua University Hospital from January 1968 to December 1988 and followed until December 1992.

Methods

The median follow-up was 112 months (range 3 to 228 months). Age at diagnosis ranged from 4 to 20 years with a mean age of 15 years and a male/female ratio of 1:2.9. A thyroid nodule or a laterocervical mass was the most frequent sign of presentation. The routine diagnosis schedule included thyroid scintigram, neck echotomography and in the last decade fine needle aspiration biopsy.

Results

Sixteen (28%) patients had a family history of thyroid disease. Histology revealed that papillary carcinoma was present in 43 patients (76.8%), follicular carcinoma in 9 (16%), medullary carcinoma in 2 (3.6%) and lymphoma in 2 (3.6%). Fifty-four patients were treated with total thyroidectomy, of these 34 had bilateral neck dissection and 20 unilateral nodal dissection; 2 patients underwent simple lobectomy with unilateral dissection. Nodal involvement was present in 41 (73%) cases, and synchronous visceral metastases were detected with scan and/or chest X-ray in 10 (18%) cases. In the case of differentiated thyroid carcinoma, patients with residual disease or thyroid remnants were treated with 131I metabolic therapy. All patients were put on suppressive hormone therapy. At this writing, 52 (93%) patients were in complete remission and 4 (7%) had persistent disease. Recurrences developed in 2 (3.5%) patients: one presented lung metachronus metastases and one local recurrence; no deaths have occurred.

Conclusions

From this experience, total thyroidectomy appears to be the appropriate approach for differentiated tumors in children and adolescents because the disease is often diffuse, secondary deposits may be easily detected, and the value of thyroglobulin measurement can be improved. Following this strategy, overall recurrence risk was low and 131I therapy was curative in patients with nodal and lung metastases.

Routine prophylactic central neck dissection for low-risk papillary thyroid cancer is not cost-effective

BACKGROUND

The role of routine prophylactic central neck dissection (CND) in papillary thyroid cancer (PTC) remains controversial. The aim of this study was to evaluate the cost utility of the addition of routine CND in patients with low-risk PTC compared with total thyroidectomy (TT) alone.

METHODS

A Markov model for low-risk PTC was constructed with a treatment algorithm based on the American Thyroid Association guidelines for well-differentiated thyroid carcinoma. Utilities and outcome probabilities were derived from published medical literature. US 2010 costs were examined from a society perspective using Medicare reimbursement rates and opportunity loss based on published US government data. Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost and utility estimates.

RESULTS

Initial TT alone is more cost-effective than TT with CND, resulting in a cost savings of US $5763 per patient with slightly higher effectiveness per patient (0·03 QALY) for a cost savings of $285 per QALY. Sensitivity analysis shows that TT alone offers no advantage when radioactive iodine (RAI) becomes more detrimental to a patient's state of health, when the incidence of non-neck recurrence increases above 5% in patients undergoing TT alone or decreases below 3·9% in patients undergoing TT with CND or when the rate of permanent hypocalcaemia rises above 4%.

CONCLUSIONS

TT with CND is not a cost-effective strategy in low-risk PTC. Initial TT alone is favourable because of the low complication rates and low recurrence rates associated with the initial surgery. Alternative strategies such as unilateral prophylactic neck dissection require additional study to assess their cost-effectiveness.

Completion thyroidectomy in differentiated thyroid cancer: When to perform?

OBJECTIVE

Completion thyroidectomy is recommended in patients who have been diagnosed with differentiated thyroid cancer on histopathological evaluation, if their first operation was a conservative approach. The critical issue is when to do the second operation.

MATERIAL AND METHODS

The medical records of 66 patients who underwent completion thyroidectomy for the treatment of differentiated thyroid cancer in our clinic between 2006-2013 were retrospectively analyzed. All data were compared after patients were divided into two groups according to the interval between the first surgery and completion thyroidectomy.

RESULTS

Fifty-two patients (78.8%) were women and 14 patients (21.2%) were male. Completion thyroidectomy was performed 10-90 days after the initial surgery (group 1) in 26 patients, whereas it was performed later than 90 days in 40 patients (group 2). Temporary hypoparathyroidism occurred in two patients (7.7%) in group 1, and in 3 patients (7.5%) in group 2. Transient recurrent laryngeal nerve palsy was observed in 1 patient (3.9%) in group 1, and in 1 patient (2.5%) in group 2. There were no permanent morbidities in both groups. Residual tumor rate after completion thyroidectomy was 45.5%. There was no statistically significant difference between the two groups in terms of complications after completion thyroidectomy.

CONCLUSION

Although in some studies it is recommended that completion thyroidectomy should be performed either before scar tissue development or after clinical remission of scar tissue, edema and inflammation, we believe that timing of surgery has no effect on morbidity.

Usefulness of electrosurgical techniques in thyroid gland surgery

Wide propagation of new generation of electrosurgical devices such as bipolar vessel sealing systems (eg. Thermostapler® by EMED) enabled seamless closing of blood vessels with a diameter up to 7 mm while maintaining the necessary safety margin, as well as reducing the duration of the operation. We decided to verify these reports in our material. AIM OF THE STUDY was comparison of thyroid surgery performed with the electrocautery tool - Thermostapler ® by EMED with surgery using classic hemostasis technique to evaluate the operative time and complications in the form of bleeding, recurrent laryngeal nerve paralysis, symptoms of hypoparathyroidism, and wound infection.

MATERIAL AND METHODS

We retrospectively analyzed 256 patients operated in the Department of General and Proctological Surgery Solec Hospital in Warsaw due to inert thyroid goitre. All patients underwent total thyroidectomy. Patients were divided into two groups. The first group consisted of 126 patients operated in 2000, using classic techniques of hemostasis. While the second group consisted of 130 patients operated in 2007-2008 with Thermostapler®. We compared duration of surgery and the incidence of postoperative complications.

RESULTS

The operative time was significantly shorter (average 18 minutes) in the second group of patients. We also recorded a statistically significant decrease in the incidence of complications in the group operated with Thermostapler.

CONCLUSIONS

Use of bipolar vessel sealing system in a decisive manner shortens the duration of operation. Use of bipolar vessel sealing system also enables a radical reduction in the incidence of complications rate such as bleeding, recurrent laryngeal nerve paralysis, symptoms of hypoparathyroidism, and wound infection. In the future, similar studies should be performed to assess the real costs resulting from the use Thermostapler®.

Completion thyroidectomy: effect of timing on clinical complications and oncologic outcome in patients with differentiated thyroid cancer

BACKGROUND

Despite improved preoperative diagnostics, incidental postoperative detection of differentiated thyroid cancer in the final histology is still common. In most of these cases, completion thyroidectomy is recommended by national and international guidelines, although secondary surgery is associated with an increased operative risk. The optimal timing of completion thyroidectomy is still controversial.

METHODS

Between January 1993 and December 2009, a total of 128 patients underwent completion thyroidectomy for differentiated thyroid carcinoma: papillary (n = 87) and follicular (n = 41). These patients were divided into five groups according to the time of the completion thyroidectomy after primary surgery (groups A, 1-3 days; B, 4-7 days; C, 1-7 weeks; D, 7-12 weeks; E, >3 months). Clinical complications and oncologic outcomes were analyzed. The mean follow-up was 82.5 ± 17 months.

RESULTS

The overall rates of transient and persistent postoperative hypocalcemia were 7.0 and 3.1%, respectively. The rates of persistent hypocalcemia were significantly increased in groups B, C, and D in comparison to those in groups A and E (p < 0.003). The hypocalcemia rates were 7.1, 4.5, and 3.8% versus 0%, respectively. Transient or persistent vocal cord paresis was observed in eight (6.2%) and four patients (3.1%), respectively. The incidence of persistent vocal cord paresis (VCP) was significantly higher in groups B, C, and D than in groups A and E (p < 0.003). The VCP rates were 7.1, 4.5, and 3.8% versus 0%, respectively. There was no significant difference regarding survival or recurrence among the five groups.

CONCLUSIONS

Considering perioperative morbidity and oncologic outcomes, completion thyroidectomy should be performed either within 3 days or beyond 3 months after primary surgery.

Telomere length is related to alternative splice patterns of telomerase in thyroid tumors

Telomere dysfunction and aberrant telomerase expression play important roles in tumorigenesis. In thyroid tumors, three possibly inhibitory splice variants of the active full-length isoform of human telomerase reverse transcriptase (hTERT) may be expressed. These variants might regulate telomerase activity and telomere length because it is the fraction of the full-length isoform, rather than the total transcript level, that correlates with enzymatic activity. Telomerase reactivation may be critical in the early stages of tumorigenesis, when progressive telomere shortening may be limiting cell viability. The aim of this study was to investigate the relationship between telomere length and hTERT splice variant expression patterns in benign and well-differentiated malignant thyroid tumors. Telomere lengths of 61 thyroid tumors were examined by fluorescence in situ hybridization, comparing tumors with adjacent normal thyroid tissue on the same slide. Expression patterns of hTERT splice variants were evaluated by quantitative and nested RT-PCR. Telomere length was inversely correlated with percentage of full-length hTERT expression rather than with total hTERT expression levels. Short telomeres and high fractions of full-length hTERT transcripts were associated with follicular and papillary thyroid carcinomas, whereas long telomeres and low levels of full-length hTERT were associated with benign thyroid nodules. Intermediate levels of full-length hTERT and telomere length were found in follicular variant of papillary thyroid carcinomas and follicular adenomas.

Can misdiagnosis in pre-operative FNAC of thyroid nodule influence surgical treatment?

BACKGROUND

Pre-operative cytology in thyroid disease remains the most appropriate diagnostic test for defining the nature of a thyroid nodule before surgical excision.

MATERIALS AND METHODS

We selected the most recent 825 surgical thyroid procedures performed in our institution from January 2004 to June 2007; 776 were total thyroidectomies, 23 were lobe-isthmectomies, and 26 were radical neck dissections. We distributed the data based on pre-operative cytology. Each cytological diagnosis was compared to results obtained by definitive histology. Tumors were called incidentalomas if they consisted of a neoplastic focus with a low grade of aggressiveness, as demonstrated by dimension <5 mm, non-aggressive histological subtype.

RESULTS

Of the 541 cases of benign disease, 417 were confirmed as benign. The other 124 cases are listed as follows: 29 follicular adenoma; 76 papillary carcinoma (35 found as incidentalomas), and 19 follicular carcinoma (3 incidentalomas). Cytology suggestive of papillary carcinoma was correct in 95.2% of cases (119/125). The 135 tumors termed "follicular neoplasm" were staged on pathology thus: 56 adenoma (41.4%), 26 carcinoma (19.2%), 13 (9.6%) absence of follicular proliferation, 38 (28.1%) papillary follicular variant, 2 (1.4%) undifferentiated cells. Medullary carcinomas were both confirmed. The "suspicious group" exhibited no malignancy on fine needle aspiration cytology (12 of 21; 57%).

CONCLUSIONS

Cytology has good reliability in malignant lesions. Incidental tumors occurring in benign disease have little impact on clinical and surgical management; "follicular neoplasm" posed two problems - the impossibility of identifying the nature of the tumor, as well as the newer difficulty in distinguishing papillary follicular subtype.

Old and new insights in the treatment of thyroid carcinoma

Thyroid cancer is the endocrine tumor that bears the highest incidence with 33 550 new cases per year. It bears an excellent prognosis with a mortality of 1530 patients per year (Jemal et al.; 2007). We have been treating patients with thyroid carcinoma during many years without many innovations. Recently, we have assisted to the development of new agents for the treatment of this disease with unexpected good results. Here we present a review with the old and new methods for the treatment of this disease.

Permanent hypocalcemia in patients operated for thyroid carcinoma

AIM AND OBJECTIVE

The incidence and risk factors for permanent hypocalcemia in thyroid carcinoma were investigated.

MATERIALS AND METHODS

The records of 417 patients were reviewed retrospectively at tertiary oncology referral center. Total or subtotal thyroidectomy patients constituted group I (n = 225), reoperative thyroid surgery patients constituted group II (n = 106), and therapeutic neck dissection cases constituted group III (n = 86). Age, gender, thyroid functions, pathologically verified tumor type, differentiation, localization and size, multicentricity, thyroid capsule invasion, extrathyroidal soft tissue invasion, coexistence of lymphocytic thyroiditis, metastatic lymph nodes dissected, incidental parathyroidectomy, and the type of surgery were investigated. RE SULTS: Permanent hypocalcemia was seen in 32 (7.7%) patients. The incidence of permanent hypocalcemia for each group was 1.7%, 10.3% and 19.7%, respectively. Related risk factors were hyperthyroidism for group I [adjusted relative risk (RR) = 21.1, 95% confidence interval (CI) = 2.6-165, p = 0.01] incidental parathyroidectomy for group II (RR = 7.8, 95% CI = 1.9-31.0, p = 0.004), and extrathyroidal soft tissue invasion (RR = 3.1, 95% CI = 1.1-9.5, p = 0.03) for group III.

CONCLUSION

Permanent hypocalcemia rate was increased with reoperative thyroid surgery and neck dissection added to total thyroidectomy. Hyperthyroidism, incidental parathyroidectomy and extrathyroidal extension were related risk factors.

Evidence-based surgical management of substernal goiter

BACKGROUND

A number of reports have been published concerning the surgical treatment of substernal goiters; however, there is yet to be a comprehensive review of this body of literature using evidence-based methodology.

METHODS

This article is a systematic review of the literature using evidence-based criteria and a review of unpublished data from our institution.

RESULTS

Issue 1. Limited level III/IV data suggest that the incidence of cancer in substernal goiters is not higher than the incidence of cancer in cervical goiters. Risk factors for malignancy in substernal goiters may include a family history of thyroid pathology, a history of cervical radiation therapy, recurrent goiter, and the presence of cervical adenopathy (grade C recommendation). Issue 2. Prospective level V data suggest that, for most patients, expert endocrine surgeons utilize an extracervical approach approximately 2% of the time to remove a substernal goiter safely; a sternotomy or thoracotomy appears more likely in cases of a primary substernal goiter or a mass larger than the thoracic inlet (no recommendation). Issue 3. There may be a higher rate of permanent hypoparathyroidism and unintentional permanent recurrent laryngeal nerve injury when total thyroidectomy is performed for removal of a substernal goiter than for removal of a cervical goiter alone (grade C recommendation). Injury of the external branch of the superior laryngeal nerve was not specifically addressed and is almost certainly underreported. Issue 4. The presence of a substernal goiter, especially being present more than 5 years and causing significant tracheal compression, is likely a risk factor for tracheomalacia and tracheostomy (grade C recommendation). Tracheomalacia with substernal goiter is an infrequent occurrence, and many cases of tracheomalacia can be managed without tracheostomy (no recommendation). Issue 5. Prospective level V data suggest that about 5% to 10% of operations for substernal goiters are performed because of recurrent or persistent disease, although retrospective level V data report an even higher rate, up to 37%. The most common initial operations with recurrence or persistence appear to be subtotal or hemithyroidectomy (no recommendation).

CONCLUSION

Evidence-based recommendations provide reliable information regarding the pathologic findings and operative management of substernal goiters in expert hands.

Completion Thyroidectomy Versus Total Thyroidectomy: Is There a Difference in Complication Rates? An Analysis of 350 Patients

BACKGROUND

This study compared our experience with completion thyroidectomy (CT) and total thyroidectomy (TT) in the management of well-differentiated thyroid cancer (WDTC). We compared complication rates and analyzed the implications of the intraoperative management of the parathyroid glands.

STUDY DESIGN

We performed a retrospective cohort study comparing outcomes between patients undergoing CT and TT between January 1994 and December 2004. All patients had surgery for either suspected or confirmed WDTC on fine-needle aspiration.

RESULTS

There were 201 CTs and 149 TTs. Mean hospital stays were 4.5 and 3.5 days for the CT and TT groups, respectively (p=0.001). Temporary recurrent laryngeal nerve paresis occurred in 2.0% (4 of 201) and 3.3% (5 of 149) of patients in the CT and TT groups, respectively. There was one (0.5%) case of permanent recurrent laryngeal nerve paralysis in the CT group. Permanent hypoparathyroidism rates were 2.5% and 3.3% in the CT and TT groups, respectively. There was no difference between the two groups in terms of total numbers of parathyroid glands autotransplanted (p=0.63) or present in the specimen (p=0.26).

CONCLUSIONS

Completion thyroidectomy is a safe and appropriate option in the management of select cases of WDTC in which a definitive preoperative or intraoperative diagnosis is not available. But it requires a longer hospitalization, so it has implications for both hospital resources and the patients involved.

Central Lymph Node Dissection in Differentiated Thyroid Cancer

BACKGROUND

There has been renewed interest in extensive lymph node dissection for papillary thyroid cancer (PTC), and a number of reports have been published concerning compartment-oriented dissection of regional lymph nodes in PTC. A comprehensive review of this body of literature using evidence-based methodology is pending.

METHODS

Systematic review of the literature using evidence-based criteria.

RESULTS

Issue 1: Systematic compartment-oriented central lymph node dissection (CLND) may decrease recurrence of PTC (Levels IV and V data, no recommendation) and likely improves disease-specific survival (grade C recommendation). Limited level III data suggest survival benefit with the addition of prophylactic dissection to thyroidectomy (grade C recommendation). The addition of CLND to total thyroidectomy can significantly reduce levels of serum thyroglobulin and increase rates of athyroglobulinemia (level IV data, no recommendation). Issue 2: There may be a higher rate of permanent hypoparathyroidism and unintentional permanent nerve injury when CLND is performed with total thyroidectomy than for total thyroidectomy alone (grade C recommendation). Issue 3: Reoperation in the central neck compartment for recurrent PTC may increase the risk of hypoparathyroidism and unintentional nerve injury when compared with total thyroidectomy with or without CLND (grade C recommendation), supporting a more aggressive initial operation.

CONCLUSION

Evidence-based recommendations support CLND for PTC in patients under the care of experienced endocrine surgeons.

SAFETY OF TOTAL THYROIDECTOMY

BACKGROUND

Total thyroidectomy is the preferred operation for multinodular goitre, Graves' disease and thyroid cancer. This study reviewed prospectively collected data on a personal consecutive series of 336 total thyroidectomies to assess whether results reported in world centres of excellence could also be achieved elsewhere.

METHODS

Between 1991 and 2004, 336 total thyroidectomies (85% over the last 6 years) of median age 53 years (13-86 years) and male : female ratio of 1:4.3 were undertaken for multinodular goitre 232 (69%), Graves' disease 26 (7.7%), thyroid cancer 60 (17.9%) and other benign conditions 17 (5.4%). Thirty-nine patients had 2-stage procedures. No patient required median sternotomy. Parathyroid autotransplantation was carried out in 43 (12.8%).

RESULTS

Permanent unilateral recurrent laryngeal nerve palsy occurred in 0.3% and permanent hypoparathyroidism in 1.8%. Significant temporary hypocalcaemia occurred in 13.4%. Non-significant temporary hypocalcaemia occurred in 23.8%, resulting in an overall rate of hypocalcaemia of 38.9% for the total series. Hypocalcaemia was more common after 1-stage compared with 2-stage surgeries (P < 0.001). Temporary hypocalcaemia was commoner after surgery for Graves' disease than surgery for other conditions. The rate of postoperative haemorrhage was 0.9% and wound infection, 1.5%. There was no postoperative mortality.

CONCLUSION

Total thyroidectomy removes the disease process completely, lowers local recurrence rates and avoids the substantial risks of reoperative surgery. Total thyroidectomy is safe and can be carried out with low complication rates that are equal to world centres of excellence.

Surgical Treatment of Solitary Thyroid Nodules Via Fine-Needle Aspiration Biopsy and Frozen-Section Analysis

BACKGROUND

Fine-needle aspiration biopsy (FNAB) and frozen-section analysis of managing solitary thyroid nodules continue to generate considerable controversy.

METHODS

This study was a retrospective review of 619 patients with solitary thyroid nodules who underwent thyroidectomy.

RESULTS

Of 540 FNABs, 35 (6.5%) were positive for malignancy, 276 (51.1%) were benign, and 229 (42.4%) were suspicious. Only 5.1% were false negative, and 11.4% were false positive. Diagnostic FNAB sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for malignancy were 86.1%, 59.7%, 33.0%, 94.9%, and 64.6%, respectively. Of 569 patients analyzed by frozen section, diagnosis was deferred in 86 (15.1%) patients, and results were positive for malignancy in 92 (16.2%) and benign in 391 (68.7%). No false-positive results were noted, but 2.3% (391) were false negative. Of 86 deferred frozen sections, 11 (12.8%) patients had malignant tumors confirmed by permanent section. Diagnostic frozen-section sensitivity, specificity, PPV, NPV, and accuracy for carcinoma were 82.1%, 100%, 100%, 95.8%, and 96.5%, respectively. Sensitivity, specificity, PPV, NPV, and accuracy for frozen-section analysis for diagnosis of carcinoma in patients with suspicious FNAB were 83.9%, 100%, 100%, 94.9%, and 96.0%, respectively.

CONCLUSIONS

FNAB is a sensitive diagnostic modality in selecting patients who require surgery. Routine use of frozen-section analysis is unwarranted for benign FNAB results. Frozen section is specific and cost-effective in determining the extent of surgery in patients with suspicious or malignant FNABs.

Selective surgery and adjuvant therapy based on risk classifications of well-differentiated thyroid cancer

BACKGROUND

The prognosis of well-differentiated thyroid cancer has been stratified into low- and high-risk groups. These risk groups can be used to predict prognosis and to guide treatment.

METHODS

Retrospective study of 962 patients with well-differentiated thyroid cancer treated from 1940 to 1998. Stratification into low- and high-risk groups based on age, metastases, extent, and size (AMES). Effects on survival of surgery, lymph node dissection, and radiation therapy were examined.

RESULTS

Seven hundred twenty-eight cases were papillary and 234 were follicular carcinoma. Seven hundred-fifty cases were low risk and 207 high risk. Twenty-year survival was 97.4% in the low-risk patients and 54.0% in high-risk patients (P < 0.001); it was 63.2% in the younger high-risk group and 41.0% in the older high-risk group (P < 0.001). Older high-risk patients had a survival advantage with bilateral thyroidectomy. Extent of surgery did not change survival in either the younger high-risk group or the low-risk group. Lymph node dissection and radioactive iodine ablation did not have an impact on survival.

DISCUSSION

Well-differentiated thyroid cancer in low-risk patients has a favorable outcome regardless of treatment. Low-risk patients can be safely treated with unilateral thyroidectomy alone. Risk stratification with a modification of the AMES criteria can be used to guide treatment.

Intraoperative electromyographic monitoring of the recurrent laryngeal nerve in reoperative thyroid and parathyroid surgery

BACKGROUND

Injury to the recurrent laryngeal nerve (RLN) is a rare complication of initial thyroid and parathyroid surgery, but the prevalence is much higher in the reoperative setting. The use of continuous, intraoperative electromyographic monitoring of the RLN has been suggested to improve the safety of cervical explorations.

METHODS

Outcomes of a group of reoperative thyroid and parathyroid cases that used EMG monitoring with endoscopically applied hook-wire electrodes were compared with a group of cervical reoperations without monitoring. Office laryngoscopy (indirect or fiberoptic) was used to evaluate and follow suspected RLN complications.

RESULTS

Electromyography was used in 52 cervical reexploration procedures. Patients averaged 1.8 previous explorations (range, 1-7 explorations) and underwent procedures for parathyroid (31%) and/or thyroid (77%) disease (overall, 72% malignant). The non-monitored group had 59 patients with similar characteristics. Only 1 permanent nerve complication in each group was unintended (electromyography, 1.9%; non-electromyography, 1.7%). Seven false-negative and 2 false-positive electromyographic findings occurred. No complications resulted from placement of the electromyography electrodes.

CONCLUSIONS

Intraoperative electromyographic monitoring of the RLN in reoperative neck surgery can be performed safely but did not decrease RLN complications in this study. Experience and routine nerve exposure remain crucial to the minimization of RLN complications.

Fine-Needle Aspiration Biopsy Findings Suspicious for Papillary Thyroid Carcinoma: A Review of Cytopathological Criteria

OBJECTIVES/HYPOTHESIS

The objective was to evaluate the usefulness of standard suspect cytological features on fine-needle aspiration biopsy (FNAB) in predicting papillary thyroid carcinoma.

STUDY DESIGN

Retrospective chart review of consecutive fine-needle biopsies of the thyroid.

METHODS

The study was a retrospective review of consecutive patients presenting with a diagnosis of suspected (group 1) or positive papillary thyroid carcinoma (group 2). The frequency of standard cytological features (i.e., papillary architecture, multinucleated giant cell, nuclear pseudo-inclusions, nuclear grooves, micronucleoli, powdery chromatin, and psammoma bodies) were recorded for each group. These were compared using chi test. Sensitivity and specificity for both individual and a combination of features were calculated for patients in group 1.

RESULTS

One hundred eight patients were eligible for the study (group 1, n = 57; group 2, n = 51). Fifty-one patients (89%) in group 1 and all patients in group 2 had a histopathological diagnosis of papillary thyroid carcinoma. Respectively, the most frequent features present on fine-needle aspiration biopsy in group 1 versus group 2 were nuclear grooves (79% vs. 88%), micronucleoli (74% vs. 86%), pseudo-inclusions (58% vs. 88%), and powdery chromatin (47% vs. 59%); P values for these features were P > .05, P > .05, P < .05, and P > .05, respectively. In group 1, the sensitivities of nuclear grooves and micronucleoli were 80% and 71%, respectively. The presence of psammoma bodies was associated with a specificity of 100%. A combination of nuclear grooves, micronucleoli, pseudo-inclusions, powdery chromatin, and multinucleated giant cells was 100% specific in detecting papillary thyroid carcinoma.

CONCLUSION

In choosing the most appropriate management of a finding suspect for papillary thyroid carcinoma on fine-needle aspiration biopsy, the surgeon must be aware of the diagnostic importance of certain cytopathological features. The presence of a combination of these factors may allow a more confident surgical approach.

Human telomerase reverse transcriptase gene expression and the surgical management of suspicious thyroid tumors

PURPOSE

Patients with a preoperative cytologic diagnosis of a suspicious thyroid nodule present a therapeutic dilemma because surgery differs for benign and malignant lesions. To address this issue, several molecular markers, including human telomerase reverse transcriptase (TERT), have been tested as markers of thyroid cancer. Because most studies select cases falling into well-defined categories to test new markers, they may overestimate their discriminatory power when applied to samples that are difficult to classify. Fine-needle aspirates (FNAs) of the thyroid with indeterminate cytology are an example of such cases.

EXPERIMENTAL DESIGN

We examined whether assessing TERT mRNA by reverse transcription-PCR could have improved the surgical management in a cohort of 100 patients undergoing thyroidectomy for indeterminate FNA results.

RESULTS

Ninety percent of 48 cancers were TERT positive, as were 35% of 52 benign lesions. When 10 cases with concomitant lymphocytic thyroiditis were excluded, the overall sensitivity of TERT was 91% (95% confidence interval, 80-98%) and specificity was 79% (64-90%). No clinical or tumor variable contributed to the predictive ability of TERT except for tumor size, which added only marginally. Basing the surgical approach on the TERT assay alone would have reduced lobectomies performed for malignant disease from 11 to 4 cases and reduced total thyroidectomies for benign lesions from to 15 to 9, an overall 50% reduction in suboptimal treatment.

CONCLUSIONS

The overall performance of preoperative differential diagnosis for thyroid tumors with indeterminate FNA results can be substantially improved by the inclusion of molecular markers such as TERT.

[Second hemithyroidectomy for thyroid carcinoma. Our experience]

Carcinomas as casual findings can be found in thyroid surgery. After the definitive AP result of malignant pathology, if a partial technique was performed, we can face problem of completing or not to a total thyroidectomy. We are reporting our 12 years experience about reinterventions because a diagnosis of thyroid carcinoma (hemithyroidectomies on previous one) was made after an anatomopathologic (AP) study on a sample from the first surgery for a supossed benign pathology. 18 patients have been studied, all of them were women, 45 year-old average and we have analysed the initial symptoms, results of basical complementary tests, diagnosis AP for first surgery and final result for second one. The incidence of malignancy showed in our series after the second intervention was 40% so we feel that a total thyroidectomy must be performed after a casual finding of thyroid carcinoma, because this allows oncological safety and a better control of the patient.

Comparison of completion thyroidectomy and primary surgery for differentiated thyroid carcinoma

AIM

The objective of this study is to analyze the complication rates after the completion thyroidectomy and compare them with primary total thyroidectomy.

METHODS

The outcomes of patients with differentiated thyroid carcinoma who were operated over a period of eight years were evaluated. One hundred and forty-one patients underwent completion thyroidectomy and 92 patients had primary surgery.

RESULTS

The two groups were comparable in respect of clinical variables. Residual tumor was found in 66 of 141 patients (46.8%) in completion thyroidectomy group. The rate of the two most important complications, permanent recurrent laryngeal nerve palsy and permanent hypoparathyroidism were 3.5 and 4.2%, in completion thyroidectomy group, and 3.3 and 4.3%, in primary total thyroidectomy group. The complication rates were not significantly different between groups.

CONCLUSION

In conclusion, completion thyroidectomy can be done safely in a specialized center with acceptable morbidity.

Prevention, evaluation, and management of complications following thyroidectomy for thyroid carcinoma

The rate of complications during thyroid surgery has decreased because of better instrumentation, illumination, and surgical expertise. Despite these improvements, certain patients, those requiring reoperation, those with invasive cancers or with numerous nodal metastasis or recurrent tumors, and those with large substernal goiters have a low but appreciable risk for complications. When planning a thyroid operation, one should perform the operation that corrects these problems and decreases the risk for complications. Localization of at least one parathyroid gland is essential. No surgical procedure can be done, however, without a risk of complications. To decrease these possible risks the surgeon should understand the embryologic development of the thyroid and parathyroid glands, the anatomical position of key structures, and use meticulous operative technique. Experience in performing thyroid operations is essential for the best outcome with the fewest complications.

Minimally invasive video-assisted thyroidectomy for papillary carcinoma: a prospective study of its completeness

BACKGROUND

The effectiveness of minimally invasive video-assisted thyroidectomy (MIVAT) in papillary thyroid carcinoma is still debated. Some are concerned about this procedure in patients with thyroid cancer. This prospective study aimed to demonstrate that near-total thyroidectomy can be performed by MIVAT with similar results compared with open thyroidectomy.

METHODS

A total of 33 patients with a thyroid nodule proven to be a papillary thyroid carcinoma underwent a near-total thyroidectomy. They were randomly assigned to group A (n = 16) or group B (n = 17) who were treated either by MIVAT or conventional near-total thyroidectomy, respectively. Iodine-131 thyroid bed uptake and serum thyroglobulin were measured 1 month after operation. Data were analyzed by unpaired t test and Mann-Whitney statistic methods.

RESULTS

. Mean iodine-131 uptake was 5.1 +/- 4.9% in group A and 4.6 +/- 6.7% in group B. Mean thyroglobulin serum levels were 5.3 +/- 5.8 ng/mL in group A and 7.6 +/- 21.7 ng/mL in group B. The differences were not statistically significant.

CONCLUSIONS

The results of this study showed that the completeness obtained with MIVAT is similar to that obtained with open thyroidectomy, with the great advantage of a minimal neck wound. No conclusions can be drawn in terms of influence of MIVAT on the outcome of the patients with small papillary thyroid carcinoma.

Safety of completion thyroidectomy following unilateral lobectomy for well-differentiated thyroid cancer

OBJECTIVES

When a diagnosis of thyroid cancer is returned following unilateral lobectomy, removal of the contralateral lobe is frequently necessary. Morbidity for completion thyroidectomy includes a reported 2% to 5% risk of recurrent laryngeal nerve (RLN) injury and an 8% to 15% incidence of hypoparathyroidism. In this study, to determine morbidity following completion thyroidectomy, we reviewed our results of reoperative surgery among patients with thyroid cancer.

STUDY DESIGN

Retrospective chart review.

METHODS

Between 1997 and 2000, 36 consecutive patients, 32 females and 4 males, with a mean age of 43.6 years (range, 19-59 y), underwent completion thyroidectomy. Preoperative fine-needle aspiration revealed follicular derived neoplasm in 32 patients (88.9%), indeterminate in 3 patients (8.3%), and Hürthle cell neoplasm in 1 patient (2.8%). The interval between the first and second operation was a mean of 43.3 days (range, 2-103 d).

RESULTS

At the primary surgery, 29 patients (80.6%) had a follicular variant of papillary carcinoma, 6 (16.7%) had follicular carcinoma, and 1 (2.8%) had Hürthle cell carcinoma. Of these, 14 had multifocal disease. In the completion lobe, 20 patients (55.6%) had evidence of thyroid carcinoma. There was a 0% incidence of RLN injury, and the mean pre- and post-completion thyroidectomy serum calcium was 8.9 mg/dL and 8.6 mg/dL, respectively. There was one postoperative hematoma, requiring re-exploration. Five patients (13.9%) had a transient postoperative serum calcium (Ca) <8.0 mg/dL, with one being symptomatic. None required vitamin D or prolonged calcium supplementation.

CONCLUSIONS

When completion thyroidectomy is necessary for the treatment of thyroid malignancy, the procedure can be performed safely with low morbidity and is effective for diagnosing and removing occult disease in the remaining thyroid.

Tracheal invasion by thyroid carcinoma: prediction using MR imaging

OBJECTIVE

The purpose of this study was to evaluate the accuracy of MR imaging in predicting tracheal invasion by thyroid carcinomas and to determine MR imaging criteria for diagnosing tracheal invasion.

MATERIALS AND METHODS

MR imaging was performed on the normal trachea of one cadaver and 30 healthy subjects as a standard of reference. Then, MR imaging findings in 67 patients with thyroid carcinoma were reviewed and correlated with surgical and pathologic findings. A logistic regression model was used to determine which MR imaging features were significant for predicting tracheal invasion.

RESULTS

Twenty-three (34%) of the 67 patients had tracheal invasion. Logistic regression model analysis revealed that significant MR characteristics for determining tracheal invasion included soft-tissue signal in the tracheal cartilage (p < 0.001), intraluminal mass (p < 0.001), and degree of tumor circumference around the trachea (p = 0.001). The highest accuracy (90%) for determining tracheal invasion was achieved using a combination of findings. A case was considered positive for tracheal invasion if there was soft-tissue signal in the cartilage, an intraluminal mass, or a tumor that abutted a circumference of the trachea of 180 degrees or greater. Using these factors resulted in seven false-positive diagnoses because soft-tissue signal in the cartilage was sometimes seen in healthy trachea. Although intraluminal mass invariably reflected deep tracheal invasion, soft-tissue signal in the cartilage rarely indicated actual cartilage invasion but rather indicated tumor extension between the cartilaginous rings.

CONCLUSION

Tracheal invasion by thyroid carcinomas can be accurately diagnosed with MR imaging, and using a combination of criteria is the most accurate method of predicting this phenomenon.

Conservative management of patients with intrathyroidal well-differentiated follicular thyroid carcinoma

BACKGROUND

Total or near-total thyroidectomy for the treatment of follicular thyroid carcinoma (FTC). The prognosis of patients with low-risk FTC, however, is excellent, and thus total thyroidectomy may not be justifiable in such patients.

METHODS

A retrospective review identified 61 patients diagnosed with intrathyroidal well-differentiated FTC between 1958 and 1991.

RESULTS

Median age at diagnosis was 42 years (range, 15-78 years). Most patients (90.2%) had a lobectomy or subtotal thyroidectomy. Median tumor size was 3.0 cm (range, 0.9-9.5 cm). Fifty-eight patients (95.1%) received thyroid hormone supplementation, and 5 (8.2%) received radioactive iodine ablation postoperatively. Median follow-up was 11 years (range, 3-35 years). Local recurrence, metastasis, or both developed in 3 patients (4.9%), and all subsequently died of thyroid cancer. The cumulative 10- and 15-year cancer-specific survival rate was 96.5%. Factors significantly related to worse survival were oxyphilic histology (log-rank, P =.00) and tumor size of more than 4 cm (P =.001). However, neither was found to be an independent predictor of outcome by Cox multivariate analyses (P =.7 and.9, respectively). The extent of initial operation (unilateral versus bilateral procedure) was not significantly related to survival (P =.52).

CONCLUSION

Conservative management consisting mainly of lobectomy or subtotal thyroidectomy and thyroid hormone supplementation is associated with favorable outcome of patients with intrathyroidal well-differentiated FTC.

Human telomerase reverse transcriptase expression in Diff-Quik-stained FNA samples from thyroid nodules

Fine-needle aspiration (FNA) is a highly sensitive method in the differential diagnosis of thyroid nodules. However, 10% of thyroid FNAs are indeterminate for cancer, and thus additional markers may be useful diagnostically. The authors have demonstrated previously that human telomerase reverse transcriptase (hTERT) gene expression is useful in the distinction of benign lesions from malignant lesions. They therefore wondered whether the detection of hTERT gene expression was feasible using archival slides. To establish an experimental system, ribonucleic acid was extracted from human anaplastic thyroid carcinoma cell line (ARO) in cytologic specimens, and reverse transcription-polymerase chain reaction (RT-PCR) for hTERT expression was performed. RT-PCR analysis for hTERT gene detection was then performed using 58 Diff-Quik-stained archival FNA samples collected retrospectively. RT-PCR for human thyroglobulin (hTg) or beta-actin gene expression served as a positive control. Successful PCR results were obtained from 48 of the 58 cases. All 10 slides in which no RT-PCR products were noted were older than 3 years. hTERT gene expression was demonstrated in FNAs from two of seven cases (29%) of hyperplastic nodule, one of one case (100%) of Hashimoto's thyroiditis, three of eight cases (38%) of follicular adenoma, three of eight cases (38%) of Hürthle cell adenoma, three of four cases (75%) of follicular carcinoma, two of two cases (100%) of Hürthle cell carcinoma, and 11 of 18 cases (61%) of papillary carcinoma. All but one of the available 33 corresponding frozen samples exhibited the same RT-PCR results. This study demonstrates that Diff-Quik-stained thyroid FNA specimens less than 3 years old can be used for the detection of hTERT gene expression by RT-PCR. This test, along with careful cytopathologic examination, may improve our ability to differentiate benign lesions from malignant lesions in indeterminate FNA samples from thyroid nodules.

Evaluation of Serum Calcium Levels in Predicting Hypoparathyroidism after Total/Near-Total Thyroidectomy or Parathyroidectomy

Hospital stays for thyroid and parathyroid surgery have decreased significantly with selected patients staying under 8 hours. Strategies to recognize hypocalcemia postoperatively vary. We examined timed postoperative calcium levels to determine how long one needs to monitor patients for hypoparathyroidism. We analyzed 120 consecutive patients having total/near-total thyroidectomy and/or parathyroidectomy between April 1998 and October 1999. Total and ionized serum calcium levels were obtained at 8, 16, and 22 hours postoperatively. Strict criteria for significant hypoparathyroidism were defined as a symptomatic patient, a total calcium value of less than 7.2 mg/dL, or an ionized calcium value of less than 1.0 mmol/L. Eighteen patients (15%) met criteria for hypocalcemia. The 8-hour ionized calcium level identified 40 per cent of those that needed supplementation. With the inclusion of the 16-hour ionized calcium value 94.5 per cent of patients who met criteria were identified. Of the 74 patients who had not previously received calcium at 22 hours after surgery only one patient with hypocalcemia was identified. Serial calcium values postoperatively add to the costs associated with an overnight hospital stay. In addition to clinical examination an ionized calcium level 16 hours postoperatively is sufficient to identify significant hypoparathyroidism in the majority of patients.

Surgical management of thyroid cancer

OBJECTIVE

To present an overview of surgical management of differentiated thyroid cancer.

METHODS

Evaluation of the thyroid nodule, assessment of indications for surgical treatment, analysis of the extent of surgical excision, and recommendations for lymph node dissection are addressed.

RESULTS

In a patient with a thyroid nodule, certain historical information (such as prior irradiation to the head and neck or a family history of thyroid carcinoma) and physical findings (for example, a nonfunctioning, solitary thyroid nodule) increase the likelihood of a thyroid malignant lesion. Some indications for surgical intervention are a diagnosis of cancer on fine-needle aspiration biopsy, the presence of a cold nodule, or the presence of a large thyroid lesion, especially one that causes symptoms such as hoarseness or dysphagia. Although the extent of surgical excision is controversial, the presence of metastatic lesions, extrathyroidal extension, and multicentricity all are indications for total thyroidectomy. Grossly enlarged lymph nodes should be surgically excised. Probe-guided surgical resection is a promising advance in the management of persistent or recurrent thyroid carcinoma.

CONCLUSION

Most patients with differentiated thyroid cancer have an excellent prognosis. Appropriate management is the key to minimizing morbidity and recurrences.

Familial nonmedullary thyroid cancer

Familial nonmedullary thyroid cancer is more aggressive than sporadic nonmedullary thyroid cancer. It tends to affect younger patients, and the tumors are often multi-focal and bilateral. Histologically, 90% of these tumors are papillary cancers and the remaining are Hürthle cell cancers. We recommend total thyroidectomy to remove all the thyroid tissue, which harbors the genetic defect responsible for the disease (even in low-risk patients) due to the predisposition to develop thyroid cancer and the more aggressive nature of the disease. Careful exploration of the ipsilateral lymph nodes with ipsilateral central neck dissection is encouraged to decrease a high recurrence rate (44%). A complete modified radical neck dissection should be limited to a therapeutic role because there is no clear evidence that this procedure carries any survival benefit. We also recommend that patients receive radioactive iodine ablation post-operatively, including a prophylactic dose (30 mCi) for patients with no evidence of residual uptake on the postoperative iodine 131 whole body scan and in low-risk patients using any of the prognostic scoring systems. Patients should be placed on enough thyroid hormone to suppress thyroid-stimulating hormone (TSH) to approximately 0.1 mL/mL in low-risk patients and to less than 0.1 mL/mL in high-risk patients. Focal metastatic disease in patients with familial nonmedullary thyroid cancer is best dealt with by surgical excision followed by radioactive iodine ablation when appropriate. Redifferentiation therapy has a promising role in patients who have radioactive iodine-resistant tumors. The value of prevention, early detection, and targeted gene therapy once the gene or genes responsible for familial non-medullary thyroid cancer have been identified cannot be overemphasized.

Follicular carcinoma of the thyroid gland: prognostic factors, treatment, and survival

Prognostic variables and treatment outcomes of 82 patients treated at the Northern Israel Oncology Center were reviewed. There were 59 women and 23 men in this series. The female/male ratio was 2.6/1. Median age was 46 years. Median follow-up was 11.4 (range: 3.8-24 years). Median tumor size was 3.6 cm. When first seen, 4 patients had lymph node involvement and 11 (13%) had distant metastases. Surgical treatment was total thyroidectomy in 37 patients (45%), subtotal thyroidectomy in 38 (46%), and lesser procedures in 7 (9%). Sixty-six patients (80%) were treated after surgery with 131I to ablate thyroid remnants. Doses ranged between 30 and 80 mCi. The 20-year overall actuarial survival rate was 65%. The actuarial survival rate of patients <40 years of age was 96% versus 33% in patients >50 years of age (p = 0.0008). Patients with distant metastases at presentation had inferior survival compared with patients without metastases. In conclusion, we found subtotal thyroidectomy followed by 131I and hormone therapy to provide survival similar to that with total thyroidectomy, with less morbidity. Risk factors include: age > or =40 at the time of diagnosis, presence of distant metastases, capsular invasion, tumor size > or =2 cm, and male gender.

Extent of surgery for intermediate-risk well-differentiated thyroid cancer

BACKGROUND

Methods of assigning patients with papillary or follicular thyroid cancer (well-differentiated thyroid cancer) to risk groups for the purpose of determining appropriate therapy have been developed. Despite these efforts, the optimal extent of surgery for intermediate-risk patients remains controversial.

METHODS

A retrospective study was conducted of 208 patients with well-differentiated thyroid cancer (DTC) from two institutions. Univariate and multivariate analysis of patient- and tumor-related variables was performed. A regression model was obtained, three risk groups (low, intermediate, and high) were defined, and survival curves were generated.

RESULTS

Prognostic variables were age (P <0.001), distant metastases (P <0.001), tumor size (P <0.001) and an aggressive growth pattern (P = 0.03) by univariate analysis and age (P <0.001) and distant metastases (P <0.001) by multivariate analysis. Tumor size (P = 0.07) was included in the regression model. Total thyroidectomy appeared to provide a survival advantage for intermediate risk patients. High-risk patients treated by lobectomy had a poorer prognosis.

CONCLUSIONS

Total thyroidectomy may provide a survival advantage for intermediate-risk patients with DTC. A prospective randomized trial with 200 such patients is required to confirm this finding.

Total thyroidectomy for differentiated thyroid carcinoma: primary and secondary operations

AIMS

There is considerable controversy concerning the most appropriate surgical treatment of patients with differentiated thyroid carcinoma (DTC). Although some authors have advocated subtotal thyroidectomy because of the decreased surgical morbidity and the lack of improved survival with a more extensive procedure, total thyroidectomy has been defended by others as a treatment of choice with lower morbidity.

METHODS

We reviewed 106 consecutive patients who had been treated with total thyroidectomy for DTC to determine the complication rate. Forty-seven patients had primary operations and 59 had reoperations with completion of total thyroidectomy.

RESULTS

Residual tumour in the remnant thyroid tissue was found in 53.8% of patients who underwent prophylactic completion thyroidectomy. Permanent hypoparathyroidism was present in one (0.9%) patient and accidental transient unilateral recurrent laryngeal nerve injury occurred in 2.8% of the entire series. No patient had permanent bilateral recurrent nerve palsy. Furthermore, the risk of complication was not significantly different when comparing primary total thyroidectomy or completion surgery.

CONCLUSIONS

We recommend total thyroidectomy as a safe treatment for DTC with a low rate of morbidity.

Trends in treatment and long-term survival of thyroid cancer in southeastern Netherlands, 1960-1992

Thyroid cancer (TC), comprising less than 1% of all cancers in the Netherlands, has a good prognosis in general. Controversy still remains on the extent of surgical treatment and the indication for additional Iodine-131 (131I) therapy in the management of differentiated TC. The aim of this study was to describe (changes in) the treatment of TC and to determine independent prognostic factors for crude and relative survival of differentiated TC diagnosed in general hospitals. This population-based, retrospective study was based on data from the Eindhoven Cancer Registry, Comprehensive Cancer Centre South (I.K.Z.), Eindhoven, the Netherlands. Data were collected on all 343 TC patients diagnosed from 1 January 1960 to 31 December 1992. All available information on treatment (initial and additional) and survival (on 1 April 1994) were recorded. Initial surgical treatment was defined as limited or extended. Multivariate analysis of crude and relative survival to determine prognostic factors for differentiated TC was performed. Mean follow-up was 7.6 years. The proportion of patients with differentiated TC increased from 60% in 1960-1972 to 84% in 1985-1992. TC patients were treated in all hospitals in the region, approximately 2-4/year. Ninety per cent of all TC patients initially underwent surgical treatment; the extended procedures increasing from 27% in 1960-1974 to 61% in 1985-1992. 131I was also administered increasingly (from 18-44%) to patients with differentiated TC. The relative 5, 10 and 20 year survival rates for all TC were 80, 75 and 75%, respectively. In the first 5 years after diagnosis the crude death ratio was higher with the rise of age and for the follicular type and after 5 years for males and advanced disease. After inclusion of surgical treatment into the model, the estimates of the other death ratios did not change. Patients treated with 131I did better only during the first 5 years. Although the prognosis for TC patients treated in general hospitals in Southeastern Netherlands was similar to that found for patients treated in referral centres, concentration of treatment should be considered.

Completion thyroidectomy for differentiated thyroid carcinoma

Completion thyroidectomy is performed because of a deferred diagnosis of differentiated carcinoma of the thyroid or a significant thyroid remnant after initial operation. During a period of 6 years, data from 40 patients with differentiated thyroid carcinoma undergoing completion thyroidectomy were retrospectively reviewed. There were 4 men and 36 women (1:9), and the average age was 39.6+/-1.9 years (range, 20 to 62 years). The indications for the initial surgery were a solitary thyroid nodule in 36 (90%) patients, multinodular goiter in 3 (7.5%) patients, and Graves' disease in 1 (2.5%) patient. Three patients underwent completion thyroidectomy during the same hospital stay. In the remaining 37 patients, completion thyroidectomy was performed 4 to 252 days (44.1+/-7.8 days) after the initial operation. The length of hospital stay for the initial operation was not different from that for completion thyroidectomy (5.1+/-0.3 days vs. 5.2+/-0.3 days). The length of time needed to accomplish the initial operation was not different from that required for the completion thyroidectomy (122+/-7.5 minutes vs. 110.8+/-5.9 minutes). There was no 30-day perioperative mortality. The postoperative morbidity in completion thyroidectomy consisted of transient hypoparathyroidism in 3 (7.5%) patients, permanent hypoparathyroidism in 1 (2.5%) patient, transient recurrent laryngeal nerve palsy in 1 (2.5%) patient, and permanent recurrent laryngeal nerve palsy in 1 (2.5%) patient. On the other hand, one transient recurrent laryngeal nerve palsy and one transient hypoparathyroidism occurred at the initial operation. Completion thyroidectomy is a safe procedure to remove the thyroid remnant.

Total thyroidectomy does not enhance disease control or survival even in high-risk patients with differentiated thyroid cancer

SUMMARY BACKGROUND DATA

The extent of primary thyroidectomy for differentiated thyroid cancer is controversial. There are strong proponents for total thyroidectomy based on its presumed and theoretical disease control benefits. In contrast, there are equally strong advocates of less aggressive thyroidectomy with its lower hazard of parathyroid and recurrent nerve injury. The authors have addressed whether total thyroidectomy has a survival benefit justifying its use in patients with high-risk primary cancer. The major risk factors include age and the following the pathologic determinants follicular histology, vascular invasion, and extracapsular extension.

MATERIALS AND METHODS

The clinical pathologic, therapeutic, prognostic, and outcome data were reviewed in 347 patients with well-differentiated thyroid cancer. Seventy-five percent were women, 216 patients were in the younger age group (low-risk) (21-50 years), 103 were in the intermediate-risk group (51-70 years), and 28 were in the high-risk group (>70 years). Included in the high-risk pathologic category were 158 patients who had follicular histology (55), extracapsular extension (107), or vascular invasion (119). Total thyroidectomy was performed in 56 patients, near or subtotal thyroidectomy in 47 patients and lobectomy in 55 patients. The 10-year disease specific survival in the overall patient group was 82% in patients with total thyroidectomy, 78% in patients with subtotal thyroidectomy, and 89% in patients with lobectomy (p = 0.30). There was no significant survival difference according to extent of thyroidectomy in the intermediate or high-risk groups either by age or in patients who had high-risk pathologic feature.

CONCLUSIONS

Total thyroidectomy in high-risk patients with differentiated thyroid cancer (containing follicular histology, vascular invasion, or extracapsular extension) showed no benefit over partial thyroidectomy. This suggests that the general use of total thyroidectomy is not indicated, except in highly selected patients.