Management of thyroid nodules and surgery for differentiated thyroid cancer

A Comparison Between the Transoral Endoscopic Thyroidectomy Vestibular Approach and the Transareolar Approach Regarding Perioperative Complications: A Systematic Review and Meta-Analysis

The global adoption of remote thyroidectomy is increasing, with the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transareolar approach (TAA) emerging as predominant methods. However, existing meta-analyses comparing these approaches to operative surgeries and short-term postoperative complications have significant limitations. To address this gap, our meta-analysis provides a comprehensive comparison between the TOETVA and TAA, focusing on operation time, intraoperative blood loss, postoperative drainage, and hospital stay duration. It aims to offer robust insights into their relative efficacy and safety profiles. We searched SCOPUS, PubMed, Web of Science, MEDLINE, and Cochrane Library from June 2015 to January 2024 for studies comparing transoral endoscopic thyroidectomy with the vestibular approach and areolar thyroidectomy using keywords, including "transoral thyroidectomy" and "scarless thyroidectomy." Studies were included if they were randomized controlled trials, case-control studies, or prospective/retrospective cohort studies comparing the TOETVA and TAA. Exclusion criteria removed case series, cross-sectional studies, editorials, non-English language, animal studies, and irrelevant articles. Data on operative time, postoperative drainage, intraoperative blood loss, and hospital stay were extracted. The Newcastle-Ottawa Scale was used to assess study quality (all studies scored 7-8). The findings revealed that the operative time was longer among the TOETVA group, with less intraoperative blood loss (odds ratio (OR) = 13.31, 95% confidence interval (CI) = 4.44-22.19); OR = -1.61, 95% CI = -2.82 to -0.39, respectively). Regarding hospitalization duration and postoperative drainage, no discernible difference was observed between the endoscopic TAA (ETAA) and TOETVA (OR = -0.04, 95% CI = -0.24 to 0.16; OR = -6.74, 95% CI = -20.08 to 6.60, respectively). The TOETVA has advantages over the TAA in terms of intraoperative blood loss and shorter operation times. However, both approaches exhibited comparable outcomes in terms of hospital stay duration and postoperative drainage. Furthermore, extensive randomized trials are warranted.

Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Gasless Transaxillary Endoscopic Thyroidectomy for Patients With Unilateral Papillary Thyroid Carcinoma: A Retrospective Study

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) and gasless transaxillary endoscopic thyroidectomy (GTET) are 2 newly applied technologies. This study is to compare the 2 approaches from the aspects of effectiveness and safety.

MATERIALS AND METHODS

A total of 339 patients who underwent TOETVA or GTET with unilateral papillary thyroid carcinoma were enrolled in this study from March 2019 to February 2022. The 2 groups were compared in terms of patient characteristics, perioperative clinical results, and postoperative outcomes.

RESULTS

The operative time of the TOETVA group was significantly longer than the GTET group (141.39±16.11 vs. 98.45±12.24, P <0.05). The TOETVA group had advantages over GTET group when the reduction of parathyroid hormone was compared (19.18±17.43 vs. 23.07±15.72, P <0.05). Meanwhile, more parathyroids were detected in central neck specimens in GTET group (40/181 vs. 21/158, P <0.05). TOETVA had an advantage on total number of central lymph nodes over GTET (7.65±3.11 vs. 4.99±2.45, P <0.05), whereas the number of positive central lymph nodes was similar ( P >0.05). No differences were found between the 2 groups on other data.

CONCLUSIONS

TOETVA and GTET are both safe and effective for unilateral papillary thyroid carcinomas. TOETVA has advantage on protection of inferior parathyroid glands and harvest of central lymph node dissection. Meanwhile, GTET can save more time compared with TOETVA. Surgeons and patients should freely choose the approaches based on their demands.

Clinical and Ultrasonographic Features of Papillary Thyroid Carcinoma Located in the Isthmus

ABSTRACT

The aim of this research was to investigate the clinical and ultrasonographic features of papillary thyroid carcinoma (PTC) in the isthmus. A total of 823 patients with 823 PTCs including 133 in the isthmus and 690 in the lateral lobe were included in our study. All patients were confirmed by postoperative pathology. The clinical and ultrasonographic characteristics were retrospectively analyzed and compared. Univariate analysis and multivariate logistic regression analysis were performed. Multifactor analyses showed that PTC in the isthmus was significantly different from PTC originating from the lateral lobe in aspect ratio, microcalcification, extrathyroid extension, lymph node metastases, and lymph node density ( P < 0.05, for all). There were no significant differences in age, sex, tumor size, margin, halo, echogenicity, and homogeneity ( P > 0.05, for all). The results indicated that the sonographic appearances of PTC in the isthmus were relatively atypical; however, it had a higher incidence of extrathyroidal extension, central lymph node metastasis, and a tendency of higher lymph node density. Therefore, more careful ultrasound evaluation should be performed for these nodules.

Contrast-Enhanced Ultrasound Improves the Accuracy of the ACR TI-RADS in the Diagnosis of Thyroid Nodules Located in the Isthmus

OBJECTIVES

 To evaluate the diagnostic performance of the American College of Radiology (ACR) Thyroid Image Reporting and Data System (TI-RADS), contrast-enhanced ultrasound (CEUS), and a modified TI-RADS in differentiating benign and malignant nodules located in the isthmus.

METHODS

 This retrospective study was approved by the institutional review board. Informed consent was obtained. Grayscale ultrasound (US) and CEUS images were obtained for 203 isthmic thyroid nodules (46 benign and 157 malignant) in 198 consecutive patients (156 women, mean age: 44.7 years ± 11.3 [standard deviation]; 47 men, mean age: 40.9 years ± 11.0). The area under the receiver operating characteristic curve (AUC) of the diagnostic performance of the ACR TI-RADS, CEUS, and the modified TI-RADS were evaluated.

RESULTS

 Lobulated or irregular margins (P = 0.001; odds ratio [OR] = 9.250) and punctate echogenic foci (P = 0.007; OR = 4.718) on US and hypoenhancement (P < 0.001; OR = 20.888) on CEUS displayed a significant association with malignancy located in the isthmus. The most valuable method to distinguish benign nodules from malignant nodules was the modified TI-RADS (AUC: 0.863 with modified TR5), which was significantly better than the ACR TI-RADS (AUC: 0.738 with ACR TR5) (P < 0.001) but showed no significant difference with respect to CEUS (AUC: 0.835 with hypoenhancement) (P = 0.205). The diagnostic value was significantly different between CEUS and the ACR TI-RADS (P = 0.028).

CONCLUSION

 The modified TI-RADS could significantly improve the accuracy of the diagnosis of thyroid nodules located in the isthmus.

Quality of Life and Surgical Outcome of Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) versus Open Thyroid Surgery: Experience from a Single Center in Vietnam

Background

It has been widely assumed that TOETVA has demonstrated a new technique and a promising approach as it is both minimally invasive and optimally cosmetic. The objective of this study was to assess the surgical outcome, aesthetic satisfaction, and postoperative quality of life of TOETVA in comparison with open thyroid surgery. Patients and Methods. The study was designed as a prospective study, in which 121 patients from a single center in Vietnam underwent thyroid surgery, and the study was divided into two groups: 60 patients in the TOETVA group and 61 patients in the open surgery group. The patients have been followed up including surgical outcomes, cosmetic satisfaction, and quality of life. These criteria were assessed at 4 weeks, 8 weeks, and 12 weeks after the surgery using SF-36 and thyroid surgery-specific questionnaire.

Results

Patients in the TOETVA group are significantly younger than patients in the open surgery group (35.8 + 10.3 vs 46.9 + 11.5, p < 0.001). The mean operating time was longer in the TOETVA group (102.9 ± 26.1 mins) than that in the open surgery group (66.8 ± 23.8 mins) with p = 0.0001. Cosmetic outcomes and overall satisfaction were significantly greater in the TOETVA group p = 0.0001. The SF-36 QOL scores of the patients in the TOETVA group were generally higher than the open surgery group.

Conclusions

TOETVA has been widely used with a low complication rate, cosmetic appeal, and surgical efficacy. Postoperative quality of life, cosmetic outcomes, and overall satisfaction were significantly superior to the open surgery group.

Health-related quality of life in long-term differentiated thyroid cancer survivors: A cross-sectional Tunisian-based study

BACKGROUND AND AIM

The incidence of differentiated thyroid cancer (DTC) has risen dramatically worldwide. Despite an excellent prognosis, the growing DTC survivors' community often features poor health-related quality of life (HRQoL), which challenges long-term DTC care, particularly in developing Southern Mediterranean and African countries. We aimed to assess the HRQoL and to investigate its determinants in disease-free Tunisian DTC survivors.

METHODS

We conducted a three-month cross-sectional study that included 266 patients diagnosed with DTC. We assessed the HRQoL in eligible participants using the short form-36 health survey, in comparison with 76 healthy controls.

RESULTS

The 86 eligible DTC survivors were predominantly female (89.5%) with an average age of 44.3 ± 12.5 years. Physical-functioning (PF), role-physical (RP), and pain domains were substantially altered compared to the reference population. Age was negatively associated with PF, RP, role-emotional (RE), and social functioning (SF). Tumor size and lymph node metastases affected general health and PF, respectively. The cancer-free survival duration was positively correlated with mental health (MH). Poor neck scar healing and persistent post-operative hypoparathyroidism significantly deteriorate MH. Pain perception was positively correlated with the radioactive iodine cumulative dose. Subclinical hyperthyroidism significantly reduced PF and RP scores. TSH suppression was negatively and strongly correlated with MH and SF scores.

CONCLUSION

HRQoL is substantially reduced in DTC survivors compared to the normative Tunisian population. These results could be extrapolated to similar individuals in other South Mediterranean and African countries. The development of coordinated multidisciplinary aftercare interventions in this region is warranted to preserve HRQoL in DTC survivors.

Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Endoscopic Thyroidectomy Via Areola Approach for Patients With Unilateral Papillary Thyroid Carcinoma: A Retrospective Study

BACKGROUND

Endoscopic thyroidectomy via areola approach (ETA) has been widely used in thyroidectomy for many years as it can effectively avoid a scar in the neck. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is newly applied and has gained popularity quickly. This study is to compare the safety and effectiveness of TOETVA and ETA.

MATERIALS AND METHODS

A total of 95 patients who underwent TOETVA or ETA with unilateral papillary thyroid carcinoma were enrolled in this study from March 2019 to February 2020. The basic information (such as gender, age), intraoperative hemorrhage, postoperative drainage volume, hospital durations, intraoperative and postoperative complications, operative time, central lymph node dissection time, total number of central lymph nodes, and number of metastatic central lymph nodes were compared.

RESULTS

The operative time of the TOETVA group was significantly longer than the ETA group (148.11±19.78 vs. 135.90±12.77 min, P<0.05). However, the result was opposite when central lymph node dissection time was compared (10.31±2.93 vs. 12.48±3.55, P<0.05). TOETVA had an advantage on total number of central lymph nodes over ETA (7.82±3.35 vs. 5.26±2.45, P<0.05). No differences were found between the 2 groups on other data.

CONCLUSION

TOETVA and ETA have the similarity on surgical safety and effectiveness. TOETVA has its advantage on central lymph node dissection and might be a reasonable alternative for ETA and open surgery in the future.

Effect of high-quality nursing on alleviating depression and anxiety in patients with thyroid cancer during perioperative period: A protocol for systematic review

BACKGROUND

This study will assess the effect of high-quality nursing (HQN) on alleviating depression and anxiety (DA) in patients with thyroid cancer (TC) during perioperative period (PPP).

METHODS

We will search the following electronic databases (MEDLINE, EMBASE, PsycINFO, Cochrane Library, CINAHL, Web of Science, CBM, WANGFANG, and CNKI) from inception to the present and other literature sources without language limitation. All potential randomized controlled trials reporting on effect of HQN on DA in patients with TC during PPP will be considered for inclusion. Two researchers will separately carry out study selection, data extraction, and study quality evaluation. Any different opinion will be solved by a third author through discussion. All statistical analysis will be performed by RevMan 5.3 software.

RESULTS

We will appraise the effect of HQN on DA in patients with TC during PPP through assessing outcomes of depression, anxiety, pressure, quality of life, and adverse events.

CONCLUSION

This study will provide evidence to determine whether HQN is effective or not on DA in patients with TC during PPP. OSF REGISTRATION:: osf.io/sb5r8.

Cost-effectiveness of fine-needle aspiration cytology (FNAC) and watchful observation for incidental thyroid nodules

OBJECTIVES

A trial-based comparison of the use of resources, costs and health utility outcomes of fine-needle aspiration cytology (FNAC), and watchful observation for incidental small (< 2 cm) thyroid nodules was performed using data from the randomized controlled trial (RCT).

METHODS

Using data from 314 patients, healthcare-related use of resources, costs, health utility, and quality-adjusted life years (QALYs) were estimated at 12 months after first presentation of incidental thyroid nodule(s) on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for FNAC versus watchful management at 12 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data.

RESULTS

FNAC management was associated with greater use of healthcare resources and mean direct healthcare costs per patient (US$542.47 vs US$411.55). Lower mean 12-month QALYs per patient in FNAC was observed in comparison to watchful observation (0.752 versus 0.758). The probability that FNAC management was cost-effective compared with watchful management at a willingness-to-pay threshold of US50,000 per QALY gained was 26.5%.

CONCLUSION

Based on 12-month data from RCT, watchful observation appeared cost-saving compared to FNAC in patients with incidental thyroid nodules that have a low-suspicion sonographic pattern and measure between 1.0 and 2.0 cm from healthcare provider perspective. CLINICALTRIALS.

GOV IDENTIFIER

NCT02398721.

Ultrasonographic Features, Nodule Size, Capsular Invasion, and Lymph Node Metastasis of Solitary Papillary Carcinoma of Thyroid Isthmus

Objective: This retrospective study aimed to analyze the ultrasound (US) imaging features of solitary papillary thyroid carcinoma (PTC) located in the isthmus and to assess the risk factors for lymph node metastasis (LNM) and tumor capsular invasion. Methods: We included a total of 135 patients with solitary PTC located in the isthmus. All the cases underwent US, total thyroidectomy, and prophylactic central lymph node dissection. Patients' demographic and thyroid isthmus nodules' US characteristics, as well as risk factors associated with LNM and tumor capsular invasion, were analyzed. Results: It was revealed that the occurrence of LNM was higher in male patients than in female patients (P < 0.001). As risk factors, the size of PTC in the isthmus was found to be associated with LNM and tumor capsular invasion (P = 0.005 and 0.000, respectively). The area under the receiver operating characteristic curve (AUC) of the size of the isthmus PTC was 0.64 [95% confidence interval (CI) = 0.55-0.72], indicating a probability for LNM. The AUC value for tumor capsular invasion was 0.77 (95% CI: 0.68-0.83). When the threshold was set to 1.1 cm, the larger size indicated that there was a probability of occurrence of LNM with sensitivity and specificity of 47.4 and 73.7%, respectively. When the threshold was set to 0.7 cm, the larger size indicated that there was potentially a tumor capsular invasion, with sensitivity and specificity of 80.6 and 56.3%, respectively. Wider-than-tall nodules were found to be significantly different from those in LNM and tumor capsular invasion (P = 0.038 and 0.030, respectively). There were significant differences in tumor capsular invasion in extrathyroidal extension (ETE) compared with smooth or ill-defined and lobulated or irregular nodules (P = 0.017). Conclusions: This study showed that the incidence of LNM in male patients was higher than that in female ones. When a US image shows a thyroid isthmus nodule with a wider-than-tall shape, LNM and tumor capsular invasion were likely to occur. When a US image shows a thyroid isthmus nodule with an ETE, tumor capsular invasion was likely to occur. ETE and wider-than-tall may be indicators of FNA under US guidance, even though the size of thyroid isthmus nodule may be <1 cm.

Multimodal imaging of thyroid cancer

PURPOSE OF REVIEW

Thyroid cancer is the most common endocrine cancer in adults with rising incidence. Challenges in imaging thyroid cancer are twofold: distinguishing thyroid cancer from benign thyroid nodules, which occur in 50% of the population over 50 years; and correct staging of thyroid cancer to facilitate appropriate radical surgery in a single session. The clinical management of thyroid cancer patients has been covered in detail by the 2015 guidelines of the American Thyroid Association (ATA). The purpose of this review is to state the principles underlying optimal multimodal imaging of thyroid cancer and aid clinicians in avoiding important pitfalls.

RECENT FINDINGS

Recent additions to the literature include assessment of ultrasound-based scoring systems to improve selection of nodules for fine needle biopsy (FNB) and the evaluation of new radioactive tracers for imaging thyroid cancer.

SUMMARY

The mainstay of diagnosing thyroid cancer is thyroid ultrasound with ultrasound-guided FNB. Contrast-enhanced computed tomography and PET with [F]-fluorodeoxyglucose (FDG) and MRI are reserved for advanced and/or recurrent cases of differentiated thyroid cancer and anaplastic thyroid cancer, while [F]FDOPA and [Ga]DOTATOC are the preferred tracers for medullary thyroid cancer.

Safety of central compartment neck dissection for transoral endoscopic thyroid surgery in papillary thyroid carcinoma

Background

Remote access and endoscopic thyroid surgery has been gaining popularity because it allows patients to avoid a visible scar in the neck. There is limited data on transoral endoscopic thyroidectomy when it relates to patients with papillary thyroid carcinoma. We aim to evaluate the safety of ipsilateral central compartment dissection for patients who undergo transoral thyroidectomy (thyroidectomy vestibular approach–compartment lymph node dissection).

Patients and Methods

A total of 80 patients who underwent thyroidectomy vestibular approach–compartment lymph node dissection for papillary thyroid carcinoma from June 2015 to September 2016 were identified. Over the same period, a matched cohort of 80 patients who underwent open thyroidectomy with routine ipsilateral central compartment dissection was also identified (Open-compartment lymph node dissection). The two groups were analyzed in terms of patient characteristics, perioperative clinical results and post-operative outcomes.

Results

All patients were female with a mean age of 32-year. There was no difference in mean maximum tumor size and number of lymph nodes dissected. Moreover, there was no difference in average positive lymph nodes between thyroidectomy vestibular approach–compartment lymph node dissection and Open-compartment lymph node dissection (1.48 vs 1.08, P = 0.647). Operative time was longer in the thyroidectomy vestibular approach–compartment lymph node dissection group (193 vs 102 min, P &lt; 0.001). Thyroidectomy specific complications were similar with rates of temporary recurrent laryngeal nerve palsy of 6.3 vs 8.8% and temporary hypocalcemia rates of 2.5 vs 5% in the thyroidectomy vestibular approach–compartment lymph node dissection and Open-compartment lymph node dissection groups, respectively.

Conclusions

Thyroidectomy vestibular approach–compartment lymph node dissection is a feasible and safe option for select patients with papillary thyroid carcinoma who require central node dissection compared with Open-compartment lymph node dissection, and can be a viable alternative for patients wishing to avoid a visible scar.

Impact of the change from the seventh to eighth edition of the AJCC TNM classification of malignant tumours and comparison with the MACIS prognostic scoring system in non-medullary thyroid cancer

Background

In 2018, AJCC TNM staging changed for differentiated (DTC) and anaplastic (ATC) thyroid carcinoma. The impact of this change on mortality rates was investigated and compared with the MACIS prognostic score.

Methods

Analysis of a prospective database of DTC/ATC was undertaken. Patients were staged according to TNM7 and TNM8 criteria, and MACIS scores calculated. Five‐year disease‐specific mortality rates were determined. Proportions were compared with Fisher's exact and χ² goodness‐of‐fit tests.

Results

Between August 2002 and December 2016, 310 patients had primary surgery for thyroid cancer. After exclusions, 159 patients (154 DTC, 5 ATC) remained to be studied. The MACIS score was less than 6 in 105 patients (66·0 per cent), 6–6·99 in 19 (11·9 per cent), 7–7·99 in 14 (8·8 per cent) and 8 or more in 21 (13·2 per cent), with corresponding disease‐specific 5‐year mortality rates of 0, 5, 14 and 86 per cent. For TNM7 the distribution was stage I in 53·5 per cent (85 patients), stage II in 10·1 per cent (16), stage III in 14·5 per cent (23) and stage IV in 22·0 per cent (35), and differed from that for TNM8: 76·7 per cent (122), 10·7 per cent (17), 4·4 per cent (7) and 8·2 per cent (13) respectively (P < 0·001). Overall disease‐specific 5‐year mortality rates by stage for TNM7 versus TNM8 were: stage I, 0 of 85 versus 3 of 100 (P = 0·251); stage II, 0 of 16 versus 6 of 16 (P = 0·018); stage III, 3 of 23 versus 2 of 7 (P = 0·565); stage IV, 20 of 32 versus 11 of 11 (P = 0·020).

Conclusion

Compared with TNM7, TNM8 downstaged more patients to stage I and accurately reflected worse prognosis for stage IV disease. TNM8 is an inferior predictor of mortality compared with MACIS.

Using Ultrasonography to Evaluate the Relationship between Capsular Invasion or Extracapsular Extension and Lymph Node Metastasis in Papillary Thyroid Carcinomas

Background:

Previous studies have demonstrated that ultrasonography is the recommended imaging modality for preoperative staging of papillary thyroid carcinomas (PTCs). However, only a few studies have kept watch on preoperative evaluation of capsular invasion (CI) or extracapsular extension (ECE) and cervical lymph node metastasis using preoperative ultrasonography. This study aimed to investigate the relationship between the CI or ECE and the cervical lymph node metastasis in PTCs using preoperative ultrasonography and postoperative pathology in Chinese patients.

Methods:

The data of preoperative ultrasonography and postoperative pathology of 166 patients who had a definitive diagnosis of PTCs from October 2011 to July 2014 at Xuanwu Hospital, Beijing were collected and reviewed. Preoperative ultrasonic parameters of thyroid nodules were compared with those of postoperative pathological diagnoses. All the patients were divided into bilateral PTCs group (n = 42, 78 nodules) and unilateral PTCs group (n = 124, 124 nodules), and the data of the nodule sizes, CI or ECE, and cervical lymph node metastasis by preoperative ultrasonography were compared between two groups.

Results:

A total of 202 nodules of 166 patients which were confirmed by preoperative ultrasonography and postoperative pathology were analyzed. Hypoechogenicity (n = 201, 99.5%) and irregular margins (n = 167, 82.7%) were the main ultrasonic characteristics of PTCs. A significant moderate agreement between preoperative ultrasonic examination and postoperative pathology for CI or ECE (κ = 0.622, P < 0.001) was observed. The diagnostic sensitivity was 92.0%, and specificity was 71.1%. In bilateral PTCs group, 81.0% had CI or ECE, and 61.9% had cervical lymph node metastasis. In unilateral PTCs group, 76.6% had CI or ECE, and 58.1% had cervical lymph node metastasis. There were no significant differences in the incidence of CI or ECE and cervical lymph node metastasis between two groups (all P > 0.05).

Conclusions:

Ultrasonography was proved to be a valuable method for preoperative diagnosis of PTCs. Hypoechogenicity and irregular margins were strongly associated with PTCs. CI or ECE in unilateral PTCs strongly implied the cervical lymph node metastasis. Therefore, the cervical lymph nodes should be carefully examined by ultrasonography in patients with PTCs.

Quality of life after thyroid surgery

PURPOSE

The purpose of this study was to inquire how patients' quality of life is affected after thyroid surgery and the factors involved.

METHODS

A semi-structured questionnaire and the World Health Organization Quality of Life Scale (WHOQOL-BREF) were applied to 101 patients prior to surgery. Thereafter data was collected in the early and again in the late post-operative period.

RESULTS

Mean general health score for pre-operative quality of life was 6.72 ± 1.53 (3-10), mean physical field score was 22.81 ± 2.77 (17-31), mean psychological field score was 21.69 ± 2.78 (15-28), mean social field score was 11.10 ± 1.94 (5-15) and mean environmental field score was 27.86 ± 4.30 (18-39). In the early post-operative period, mean general health score was 7.05 ± 1.45 (4-10), mean physical field score was 22.84 ± 2.83 (14-29), mean psychological field score was 21.67 ± 2.32 (16-27), mean social field score was 10.89 ± 1.96 (5-15) and mean environmental field score was 28.56 ± 4.18 (18-40). In the late post-operative period, the general health score for quality of life was 7.43 ± 1.34 (4-10), mean physical field score was 23.59 ± 2.70 (17-35), mean psychological field score was 21.75 ± 2.34 (14-29), mean social field score was 11.23 ± 1.94 (6-15) and mean on-field environment score was 29.30 ± 3.96 (16-40). The pre-operative levels of symptoms were found to be higher than early and late post-operative periods.

CONCLUSIONS

Quality of life increased after total thyroidectomy and statistically significant improvement was observed in late post-operative stage.

Ultrasonographic Evaluation of Cervical Lymph Nodes in Thyroid Cancer

Objective To determine what ultrasonographic features can identify metastatic cervical lymph nodes, both preoperatively and in recurrences after complete thyroidectomy. Study Design Prospective. Setting Outpatient clinic, Department of Head and Neck Surgery, School of Medicine, University of São Paulo, Brazil. Subjects and Methods A total of 1976 lymph nodes were evaluated in 118 patients submitted to total thyroidectomy with or without cervical lymph node dissection. All the patients were examined by cervical ultrasonography, preoperatively and/or postoperatively. The following factors were assessed: number, size, shape, margins, presence of fatty hilum, cortex, echotexture, echogenicity, presence of microcalcification, presence of necrosis, and type of vascularity. The specificity, sensitivity, positive predictive value, and negative predictive value of each variable were calculated. Univariate and multivariate logistic regression analyses were conducted. A receiver operator characteristic (ROC) curve was plotted to determine the best cutoff value for the number of variables to discriminate malignant lymph nodes. Results Significant differences were found between metastatic and benign lymph nodes with regard to all of the variables evaluated ( P < .05). Logistic regression analysis revealed that size and echogenicity were the best combination of altered variables (odds ratio, 40.080 and 7.288, respectively) in discriminating malignancy. The ROC curve analysis showed that 4 was the best cutoff value for the number of altered variables to discriminate malignant lymph nodes, with a combined specificity of 85.7%, sensitivity of 96.4%, and efficiency of 91.0%. Conclusion Greater diagnostic accuracy was achieved by associating the ultrasonographic variables assessed rather than by considering them individually.

The relevance of preoperative ultrasound cervical mapping in patients with thyroid cancer

BACKGROUND

Cervical lymph node involvement in thyroid cancer is associated with locoregional recurrence and decreased disease-free survival. Preoperative lymph node mapping helps in planning surgery for neck dissection and improves patient outcomes. We sought to perform a qualitative and quantitative analysis of ultrasound mapping for thyroid cancer and evaluate the clinical importance of this exam in terms of identifying the group of patients who would benefit most from subsequent surgical dissection.

METHODS

We retrospectively reviewed the cases of 263 patients who underwent thyroid surgery between 2009 and 2013. We calculated the positive predictive values (PPVs) of ultrasound mapping of both the lateral and central compartments together and the lateral or central compartment individually. A quantitative analysis was performed by comparing the number of positive lymph nodes at ultrasound imaging with histopathologic evaluation.

RESULTS

A total of 136 cases of thyroid cancer in 120 patients met the inclusion criteria for ultrasound mapping analysis. The PPVs (and 95% confidence intervals) were 83.82 (0.76-0.89) for the lateral and central compartments, 85.39% (0.76-0.91) for the lateral compartment, and 80.48% (0.7-0.87) for the central compartment. When comparing the positive lymph nodes at ultrasound imaging with histopathologic evaluation, the result was χ(2) = 10.33 (p = 0.006).

CONCLUSION

This single-institution study indicated that preoperative ultrasound mapping is an accurate imaging procedure for predicting lymphatic spread in differentiated and medullary thyroid cancer. Ultrasound mapping can be used as an efficient tool for surgical planning and prognosis determination, as well as for identifying the group of patients who would benefit most from subsequent surgical intervention.

Prophylactic neck dissection for low-risk differentiated thyroid cancers: Risk-benefit analysis

BACKGROUND

The benefit of neck dissection is the subject of debate in differentiated thyroid cancer (DTC). We analyze the risk-benefit of neck dissection for low-risk DTC without detectable lymph nodes.

METHODS

We conducted a retrospective study from 1983 to 2003; which included 295 patients without detectable lymph nodes who were treated by thyroidectomy with (C+) or without (C-) neck dissection. All patients had iodine131 therapy. We compared the frequency of remission, disease progression, and permanent complications between groups.

RESULTS

Two hundred twelve patients comprised the C+ group, and 83 patients the C- group. Respectively for C+ versus C-, remission rates were 92% versus 89.2% (p = .40), and progressive disease observed was 3.3% versus 7.2% (p = .10). Permanent hypoparathyroidism occurred in 15.1% in C+ versus 3.6% in C- (p = .006).

CONCLUSION

The risk-benefit analysis of neck dissection in patients with low-risk DTC shows no benefit in terms of complete remission or occurrence of progression. However, risk of complications seems to be higher in patients with neck dissection. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1091-1096, 2016.

Copper as ancillary diagnostic tool in preoperative evaluation of possible papillary thyroid carcinoma in patients with benign thyroid disease

Preoperative diagnosis of papillary thyroid carcinoma (PTC) comprises numerous diagnostic procedures which are mostly applicable in tertiary institutions. Normal thyroid function depends on the presence of many trace elements and copper (Cu) and zinc (Zn) are some of those. The study is based on retrospective review of 118 patients with preoperatively diagnosed benign thyroid disease (BTD) and 12 with PTC, who underwent thyroid surgery at the Center for Endocrine Surgery Clinical Center of Serbia, Belgrade, between 2010 and 2012. The objective was to evaluate concentrations of Cu and Zn in serum as possible prediction markers for PTC in patients who underwent surgery for preoperatively diagnosed BTD. Concentrations of Cu and Zn ions in serum were measured using atomic absorption spectrophotometer. Data were analyzed using methods of descriptive statistics, Anova and t-test (p < 0.05 was considered statistically significant). Definitive pathohistological findings revealed PTC in 23 (19.5%) and papillary microcarcinoma-mPTC in 13 (11.0%) of BTD patients. The concentrations of Cu ions in serum of PTC patients as well as in serum of patients with mPTC were significantly higher than in serum of BTD patients (p < 0.05). The concentrations of Zn ions and Cu/Zn ratio in serum of PTC and mPTC patients were not significantly higher than in serum of BTD patients. The concentration of Cu ions in serum of patients before thyroid surgery can be useful, easy available, and a low-cost tool in prediction of preoperatively undiagnosed PTC in patients with BTD.

Defining the outcome of patients with delayed diagnosis of differentiated thyroid cancer

OBJECTIVES/HYPOTHESIS

In the present study we sought to define the outcome of patients with delay in diagnosis and treatment (>1 year) of well-differentiated thyroid carcinoma (WDTC) due to initial benign cytology (IBC).

STUDY DESIGN

Retrospective medical record review and analysis of survival outcomes.

METHODS

The records of 47 patients with delayed diagnosis of thyroid cancer were reviewed. In 38, surgery was performed for growing nodules and in nine due to malignant cytology during follow-up. Median time to delayed surgery was 52 months (range, 13-205 months). Multivariate analysis was performed to assess variables associated with outcome.

RESULTS

Most patients (32/47) underwent total thyroidectomy, whereas 15/47 had hemithyroidectomy. With a median follow-up of 96 months (range, 12-184 months), the 5-year disease-free survival of these patients was 96%. Multivariate analysis showed that the outcome of these patients was not statistically different than that of patients (n = 162) who underwent immediate surgery for similar disease.

CONCLUSIONS

We show that patients with delayed diagnosis and treatment for WDTC due to IBC have excellent outcome.

LEVEL OF EVIDENCE

4.

Helicobacter pylori infection is associated with the presence of thyroid nodules in the euthyroid population

Helicobacter pylori infection is associated with extragastric diseases. The thyroid may be one of the targets of chronic inflammation. Here, we sought to investigate whether H. pylori infections were associated with the presence of thyroid nodules. A total of 988 euthyroid subjects from China were included in this cross-sectional study. Four hundred thirty-five (44.0%) subjects were diagnosed as having thyroid nodules, and 486 (49.2%) were diagnosed with H. pylori infections. The thyroid nodules group had a higher proportion of H. pylori infections than the control group (P = 0.002). Free thyroxine (FT4) levels were lower and the prevalence of thyroid nodules was higher in patients with H. pylori infection compared to those without infection, even after adjustment for age, gender, and body mass index (BMI; all P < 0.05). The prevalence of H. pylori infection showed a decreasing trend as serum FT4 level increased (P_trend = 0.020). Stepwise logistic regression analysis showed that H. pylori infection was significantly associated with the risk of thyroid nodules (odds ratio: 1.390, 95% confidence interval: 1.059–1.824, P = 0.018). Our results suggested that H. pylori infections were positively associated with the presence of thyroid nodules in the euthyroid population, whose thyroid functions were in the reference range.

Intra- and postoperative complications in 137 cases of giant thyroid gland tumor

The intra- and postoperative complications resulting from surgery for giant thyroid gland tumors (diameter greater than 10 cm) present serious challenges to patient recovery. Although there are a number of methods, all have limitations. In this study, we present our experience with several complications of surgical treatment of giant thyroid gland tumors to increase the awareness and aid the prevention of these complications. A total of 137 consecutive patients who underwent surgical treatment in Henan Tumor Hospital were retrospectively analyzed. Statistics pertaining to the patients' clinical factors were gathered. We found that the most common surgical complications were recurrent laryngeal nerve (RLN) injury and symptomatic hypoparathyroidism. Other complications included incision site infections, bleeding, infection and chyle fistula, the incidence of which increased significantly with increasing extent of surgery from group I (near-total thyroidectomy) to group V (total thyroidectomy plus lateral neck dissection). Low complication rates may be achieved with more accurate knowledge of the surgical anatomy, skilled surgical treatment and experience. More extensive surgery results in a greater number of complications.

Update on thyroid cancer treatment

Surgery and radioiodine therapy are usually effective for most patients with differentiated thyroid cancer. However, poorly differentiated and anaplastic thyroid carcinomas represent a challenge to physicians on the basis of the current cancer treatment modalities. These cancer subtypes are often lethal and refractory to radioiodine therapy as well as most of the common chemotherapy drugs. Several kinase inhibitors are promising targeted therapies for these malignancies; however, clinical trials involving these drugs have provided controversial results and their clinical use is still under debate. Advanced medullary thyroid carcinomas may also be refractory to conventional therapies and novel kinase inhibitors may also be useful to control tumor progression in certain patients. Novel evidence is emerging that thyroid cancer is a stem cell disease, thereby implying that the driving force of thyroid cancers is a subset of undifferentiated cells (thyroid cancer stem cells) with unlimited growth potential and resistance to conventional therapeutic regimens. Thyroid cancer stem cells have been proposed as responsible for tumor invasiveness, metastasis, relapse and differentiation. Therefore, drugs that selectively target these cells could serve as a cornerstone in the treatment of poorly differentiated thyroid cancer.

Central compartment dissection for well differentiated thyroid cancer … and the band plays on

PURPOSE OF REVIEW

The role of central compartment dissection in the surgical management of well differentiated thyroid cancer is controversial. Lack of high-quality prospective studies results in management decisions being based on expert opinions and weaker levels of evidence. The American Thyroid Association has recently revised its management guidelines with particular emphasis on this topic, and a separate working group has set out to define the surgical anatomy that encompasses this procedure.

RECENT FINDINGS

Central compartment dissection comprises the removal of nodal tissue from the prelaryngeal, pretracheal and paratracheal compartments, with no role for berry-picking procedures. There is universal agreement that therapeutic nodal dissection should be performed in patients with metastatic disease detected either through preoperative imaging or during intraoperative evaluation of the central compartment, with either visual inspection or frozen-section pathology. In contrast, there may be limited benefit from routine prophylactic central compartment dissection, for either disease recurrence or survival outcomes. As such, it should be performed only in patients deemed high risk: larger tumors, extra-thyroidal extension or aggressive histologic subtypes.

SUMMARY

Future studies should focus on identifying the subpopulation of patients who would most benefit from these procedures and spare low-risk patients from the unwanted complications.

Controversies in the management of papillary thyroid cancer revisited

The debate on the appropriate treatment of patients with papillary thyroid cancer (PTC) has persisted for several decades. The main controversies focus on the extent of surgery, the timing of central neck dissection, and the indications for radioactive iodine ablation. These controversies continue, for the most part, due to the good prognosis of PTC patients and the questionable effect these treatment modalities have on patient survival. This paper addresses these three controversies and the role of molecular tumor markers in the appropriate treatment selection.

Advances in surgical therapy for thyroid cancer

Thyroid cancer is the most common malignancy of the endocrine system and its incidence has dramatically increased over the past three decades. Well-differentiated thyroid cancers (DTCs) are the main focus of this article, as they represent >90% of thyroid malignancies. This Review provides an overview of the controversies surrounding the optimal choice of surgery and extent of resection for patients with low-risk DTC or with papillary thyroid microcarcinoma, and the role of prophylactic central lymph node dissection. This Review also outlines the current surgical management of DTC and presents updated results for these techniques, along with important advances and current dilemmas in surgical approaches to treatment of these cancers. For example, endoscopic and robotic thyroidectomy are the two most recent innovations to present technical and other challenges to the endocrine surgeon; in addition, the risks as well as the advantages of same-day thyroid surgery, which has gained some acceptance, are detailed. Arguments for and against each approach are presented, along with supporting evidence. The authors' personal opinions are also provided for each topic.