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

Risk Factors for Anaplastic Thyroid Carcinoma: A Case Series From a Tertiary Referral Center for Thyroid Surgery and Literature Analysis

Anaplastic thyroid carcinoma (ATC) is a very rare and extremely aggressive disease with a very poor prognosis. Several risk factors have been hypothesized, but there is no clear-cut literature data on it. We reviewed the literature concerning risk factors for ATC and analyzed the institutional database from 2005 to 2022. In total, 15 papers were suitable for review, while the retrospective data collection search, conducted on our institutional database, provided 13 results. In our experience, in agreement with literature data, ATC seems to be a neoplasm peculiar to old age (in our database, mean age is 72 years), with a higher prevalence in subjects with a low level of education and a long history of multinodular goiter (MNG). The role of cigarette smoking and blood group, hypothesized on some literature data, was more uncertain, although the small sample size evaluated probably had a great influence on these results. The higher incidence of the disease in individuals with a history of MNG could suggest more aggressive choices in the treatment of a benign disease, in contrast to current practice. However, this may be a highly questionable point considering that ATC accounts for no more than 2% of all thyroid neoplasms in surgical departments, even those dedicated to endocrine neck surgery. Further studies are therefore necessary for a step forward in this direction.

Curative surgery for anaplastic thyroid carcinoma: A case report

Anaplastic thyroid carcinoma accounts for 3%–4% of thyroid malignancies worldwide and is aggressive in nature with a median survival of 6 months at diagnosis. A 67-year-old lady with a hard goitre presented with compressive symptoms and mild hypothyroidism. Ultrasound scan revealed a Thyroid Imaging Reporting and Data System 5 lesion with suspicious left-sided cervical lymphadenopathy. Anaplastic carcinoma was diagnosed by fine needle aspiration cytology. Left-sided thyroid tumour with possible carotid sheath infiltration and left-sided cervical lymphadenopathy was seen on contrast-enhanced computed tomography of the neck. She underwent total thyroidectomy with therapeutic bilateral selective central and lateral cervical lymphadenectomy. Involvement of the aero-digestive tract and carotid sheath was not observed intra-operatively. Histology reported anaplastic carcinoma with deposits of papillary carcinoma in affected lymph nodes. Oncological management was commenced thereafter. Anaplastic thyroid carcinoma usually presents as advanced disease. However, current guidelines suggest a multimodal approach comprising of curative surgery whenever feasible with adjuvant radiotherapy and chemotherapy. For patients with stage IVa/IVb loco-regional disease as in our patient, total thyroidectomy with therapeutic lymphadenectomy to achieve R0/R1 resection plus adjuvant therapy is the current accepted practice. For locally advanced disease, surgery maybe opted after down-staging. The aim is to resect tumour wholly and not merely de-bulking. The presence of papillary carcinoma in lymph nodes points towards anaplasia occurring in a background of differentiated thyroid carcinoma in our patient similar to what literature suggests. This has implications in post-operative thyroxine suppression and radioiodine ablative therapies.

Differences Between Cancer-Specific Survival of Patients With Anaplastic and Primary Squamous Cell Thyroid Carcinoma and Factors Influencing Prognosis: A SEER Database Analysis

PURPOSE

Anaplastic thyroid carcinoma (ATC) and primary squamous cell carcinoma of the thyroid (PSCCTh) have similar histological findings and are currently treated using the same approaches; however, the characteristics and prognosis of these cancers are poorly researched. The objective of this study was to determine the differences in characteristics between ATC and PSCCTh and establish prognostic models.

PATIENTS AND METHODS

All variables of patients with ATC and PSCCTh, diagnosed from 2004-2015, were retrieved from the Surveillance, Epidemiology, and End Results Program (SEER) database. Percentage differences for categorical data were compared using the Chi-square test. Kaplan-Meier curves, log-rank test, and Cox-regression for survival analysis, and C-index value was used to evaluate the performance of the prognostic models.

RESULTS

After application of the inclusion and exclusion criteria, a total of 1164 ATC and 124 PSCCTh patients, diagnosed from 2004 to 2015, were included in the study. There were no differences in sex, ethnicity, age, marital status, or percentage of proximal metastases between the two cancers; however, radiotherapy, chemotherapy, incidence of surgical treatment, and presence of multiple primary tumors were higher in patients with ATC than those with PSCCTh. Further cancer-specific survival (CSS) of patients with PSCCTh was better than that of patients with ATC. Prognostic factors were not identical for the two cancers. Multivariate Cox model analysis indicated that age, sex, radiotherapy, chemotherapy, surgery, multiple primary tumors, marital status, and distant metastasis status are independent prognostic factors for CSS in patients with ATC, while for patients with PSCCTh, the corresponding factors are age, radiotherapy, multiple primary tumors, and surgery. The C-index values of the two models were both > 0.8, indicating that the models exhibited good discriminative ability.

CONCLUSION

Prognostic factors influencing CSS were not identical in patients with ATC and PSCCTh. These findings indicate that different clinical treatment and management plans are required for patients with these two types of thyroid cancer.

Poorly Differentiated Thyroid Carcinoma: Single Centre Experience and Review of the Literature

There is controversy in the literature regarding a distinct subset of thyroid carcinoma whose histologically classification falls between well-differentiated and anaplastic carcinomas, previously identified as ‘poorly differentiated thyroid carcinoma’ (PDTC), or ‘insular carcinoma’, in view of the peculiar morphological characteristics of the cell groupings. The correct diagnosis and treatment of this entity have important prognostic and therapeutic significance. In this review, we describe the epidemiology, diagnosis, and management of PDTC and report our single centre experience to add to the limited evidence existing in the literature.

Total thyroidectomy is superior for initial treatment of thyroid cancer

PURPOSE

The incidence of thyroid cancer has increased annually, and has a heavy psychological and economic burden on the society and individuals. Based on thyroid cancer data from patients treated in Liaocheng People's Hospital in 2017, with Chinese national and regional characteristics, in this study we addressed the controversy of which initial thyroid surgical mode, lobectomy, or total thyroidectomy is the most effective.

PATIENTS AND METHODS

Clinical and pathological data from 552 patients with thyroid cancer, who were initially diagnosed and treated surgically, were collected from the Department of Thyroid Surgery. Among them, 40 patients underwent endoscopic surgery, with resection, including lobectomy + central lymph node dissection of the affected lobe, while 512 cases underwent total thyroidectomy + central lymph node dissection.

RESULTS

The metastasis rate for all patients was 59.42%, with lymph node metastasis of papillary thyroid microcarcinoma of 46.92%; however, for patients with tumors >2 cm, the proportion developing metastasis was increased to 77.53%.

CONCLUSION

In thyroid cancer, rates of neck lymph node metastasis are high, particularly among patients with risk factors for poor prognosis. Our data suggest that initial treatment should comprise at least total thyroidectomy + central lymph node dissection in China, at least in tumors larger than 1 cm, to avoid the risks associated with secondary surgery and effects on patient quality of life.

The Role of IONM in Reducing the Occurrence of Shoulder Syndrome Following Lateral Neck Dissection for Thyroid Cancer

Lateral neck dissection (LND) leads to a significant morbidity involving accessory nerve injury. Modified radical neck dissection (MRND) aims at preservation of the accessory nerve, but patients often present with negative functional outcomes after surgery. The role of neuromonitoring (IONM) in the prevention of shoulder syndrome has not yet been defined in comparison to nerve visualization only. We retrospectively analyzed 56 thyroid cancer patients who underwent MRND over a period of six years (2015–2020) in a high-volume institution. Demographic variables, type of surgical procedure, removed lymph nodes and the metastatic node ratio, pathology, adoption of IONM and shoulder functional outcome were investigated. The mean number of lymph nodes removed was 15.61, with a metastatic node ratio of 0.2745. IONM was used in 41.07% of patients, with a prevalence of 68% in the period 2017–2020. IONM adoption showed an effect on post-operative shoulder function. There were no effects in 89.29% of cases, and temporary and permanent effects in 8.93% and 1.79%, respectively. Confidence intervals and two-sample tests for equality of proportions were used when applicable. Expertise in high-volume centres and IONM during MRND seem to be correlated with a reduced prevalence of accessory nerve lesions and limited functional impairments. These results need to be confirmed by larger prospective randomized controlled trials.

Surgical Treatment of Advanced Thyroid Cancer with Tracheal Invasion

Introduction

Tracheal invasion in thyroid cancer occurs in one-third of locally advanced cases and is the third most common site of infiltration following strap muscles and recurrent laryngeal nerves. Surgical resection plays an important role in the management strategy followed by either radioactive iodine or external beam radiotherapy. Nonetheless, there has been still controversy about the optimal extension of the surgery. Case Presentation. Total thyroidectomy, airway resection and bilateral neck dissection were performed in two cases diagnosed as advanced thyroid cancer with tracheal invasion (stage IV according to McCaffrey). The first case underwent partial tracheal resection and direct anastomosis by the V-shape technique, while the latter one required tracheal resection and permanent tracheotomy. After one-year follow-up, no evidence of tumor recurrence or any postoperative complications were found.

Conclusion

Surgical resection still remains the mainstay of management for advanced thyroid cancer in general and for tracheal invasion cases in particular. The decision of surgical resection and tracheal reconstruction methods mostly depends on the extent of tracheal invasion.

Which is preferred for initial treatment of papillary thyroid cancer, total thyroidectomy or lobotomy?

Purposes

The incidence of thyroid cancer has increased annually, and has a heavy psychological and economic burden on society and individuals. Based thyroid cancer data from patients treated in Liaocheng People's Hospital from 2015 to 2018, with Chinese national and regional characteristics, in this study, we addressed the controversy of which initial thyroid surgical mode, lobectomy or total thyroidectomy, is most effective.

Methods

Clinical and pathological data from 2108 patients with thyroid cancer, who were initially diagnosed and treated surgically, were collected from the Department of Thyroid Surgery. Among them, there were 1001 cases who underwent open operation with total thyroidectomy + central lymph node dissection; meanwhile, 1107 cases were treated with neck lateral lymph node dissection at the same time.

Results

The overall metastasis rate of all patients was 57.23%. Even the lymph node metastasis of papillary thyroid microcarcinoma (PTMC) was as high as 48.97%. When the mass rose above 2 cm, the proportion of metastasis increased to 77.22%. When the tumor was complicated with bilateral and multiple high‐risk factors, the proportion of metastasis was 65.27% and 72.21%, respectively. When the tumor breaks through the capsule, the metastasis rate was 67.08%. With the increase of tumor diameter, the metastasis of cervical lymph nodes ranged from 22.54% to 73.33%, which showed positive correlation. 49.32% of patients had lymph node metastasis in the lateral cervical region. When the diameter of the tumor reached T1c level, the metastasis of the cervical lymph nodes was 56.91%, and the number of metastatic cases above T1c level accounted for 69.96% of the total metastatic cases.

Conclusion

The degree of malignancy of thyroid cancer depends on tumor genome evolution. Rates of neck lymph node metastasis are high, particularly among patients with risk factors for poor prognosis. It is recommended that initial treatment should comprise at least total thyroidectomy + central lymph node dissection in China, to avoid the risks associated with secondary surgery and effects on patient quality of life. When the tumor diameter exceeds 1 cm, the risk of cervical lymph node metastasis is high, and we recommended lateral lymph node dissection.

The Blood Biomarkers of Thyroid Cancer

Introduction

With the gradual increase in the incidence of thyroid cancer, people’s attention to thyroid cancer has also gradually increased. Although the prognosis of thyroid cancer is rather mild compared to other cancers, it will still bring a heavy psychological burden on people who have been diagnosed. At present, the diagnosis of thyroid cancer mainly depends on ultrasound and percutaneous fine needle aspiration (pFNA). Due to the unsatisfactory accuracy of the diagnosis methods we use now, there are still some thyroid nodules that cannot be clearly diagnosed before surgery.

Methods

In this article, we have searched for relevant research on blood markers of thyroid cancer in the past five years and categoried them into four groups.

Discussion

Though we have not found a biomarker which can diagnose thyroid cancer both sensitively and specifically, we do found many substances that are related to it, and have the potential to recognize it and help the diagnosis. And perhaps combined models can do it better.

With High-Risk Factors, Total Thyroidectomy is Preferred for Thyroid Cancer

Introduction

Based on thyroid cancer data from patients treated in Liaocheng People’s Hospital in 2017, with Chinese national and regional characteristics, in this study we addressed the controversy of which initial thyroid surgical mode, lobectomy or total thyroidectomy, is most effective.

Patients and Methods

Clinical and pathological data from 552 patients with thyroid cancer, who were initially diagnosed and treated surgically, were collected from the Department of Thyroid Surgery. Among them, 40 patients underwent endoscopic surgery, with resection including lobectomy + central lymph node dissection of the affected lobe, while 512 cases underwent total thyroidectomy + central lymph node dissection.

Results

The metastasis rate for all patients was 59.42%. Further, among patients with bilateral or multiple tumors or capsule invasion, the proportions who developed metastatic disease were 63.54% and 71.19% and 67.46%, respectively. Meanwhile, the incidence of contralateral accidental malignancy was 7.25% after postoperative paraffin pathology.

Discussion

Rates of neck lymph node metastasis are high, particularly among patients with risk factors for poor prognosis. It is recommended that, among patients with risk factors, initial treatment should comprise at least total thyroidectomy + central lymph node dissection in China, to avoid the risks associated with secondary surgery and effects on patient quality of life.

Isthmic Papillary Thyroid Carcinoma Presents a Unique Pattern of Central Lymph Node Metastasis

Purpose

Treatment protocols for occult central lymph node metastasis (LNM) associated with papillary thyroid cancer (PTC) located in the isthmus are debatable. We aimed to analyze the pattern of occult central LNM in isthmic PTC, including risk factors for bilateral paratracheal LNM.

Patients and Methods

Consecutive patients with PTC were recruited to this study. All patients underwent total thyroidectomy and prophylactic bilateral central neck dissection. The clinicopathologic features and distribution of central LNM were compared between the two groups, and risk factors for bilateral paratracheal LNM were analyzed.

Results

A total of 174 patients with PTC were enrolled in this study, of whom 87 patients had isthmic PTC (study group) and 87 patients had lobe-originating PTC (control group). The two groups had comparable demographics and tumor features. There were higher frequencies of pretracheal LNM (P =0.001) and bilateral paratracheal LNM (P = 0.002) in the isthmic PTC group. Bilateral paratracheal LNM was significantly associated with age <55 years (P = 0.037), capsular invasion (P = 0.034), tumor location (isthmus) (P < 0.001), BRAF gene mutation (P = 0.013), and pretracheal LNM (P < 0.001). Isthmus location (odds ratio [OR]: 4.116, 95% confidence interval [CI]: 1.264–13.433, P = 0.019) and pretracheal LNM (OR: 3.422, 95% CI: 1.214–9.642, P = 0.020) were independent risk factors for bilateral paratracheal LNM.

Conclusion

Because of its unique anatomic location, isthmic PTC differs from PTC in the lobe with respect to pretracheal and bilateral paratracheal LNM, even in patients of comparable age, sex, tumor size, extrathyroidal extension, BRAF mutation, and pathologic TNM staging. The isthmus location was found to be an independent risk factor for bilateral paratracheal LNM. This information may contribute to the development of an appropriate surgical protocol for isthmic PTC.

Clinical Analysis of Risk Factors for Cervical Lymph Node Metastasis in Papillary Thyroid Microcarcinoma: A Retrospective Study of 3686 Patients

Purpose

To investigate the risk factors for cervical lymph node metastasis (LNM) in papillary thyroid microcarcinoma (PTMC).

Patients and Methods

In total, 3686 patients with PTMC who underwent initial surgery in Shanghai Jiao Tong University affiliated Sixth People’s Hospital from January 2010 to December 2019 were retrospectively analyzed. Univariate and multivariate analyses were conducted to identify risk factors associated with cervical LNM.

Results

Male gender [odds ratio (OR) =1.420, P <0.001], age <55 years (OR =2.128, P <0.001), tumor size >6.5 mm (OR =2.112, P <0.001), lymphovascular invasion (LVI) (OR =2.110, P =0.016), multifocality (OR =1.358, P =0.022), extrathyroidal extension (ETE) (OR =1.598, P <0.001), and lateral LNM (LLNM) (OR =6.383, P <0.001) served as independent risk factors for central LNM (CLNM). Moreover, male gender (OR =1.668, P =0.001), tumor size >6.5 mm (OR =2.223, P <0.001), chronic lymphocytic thyroiditis (OR =1.402, P =0.021), LVI (OR =4.582, P <0.001), ETE (OR =1.393, P=0.023), and CLNM (OR =6.212, P <0.001) served as independent risk factors for LLNM. Furthermore, solitary PTMC with lesions in the upper third of the thyroid gland were more associated with LLNM than lesions in the other regions.

Conclusion

This study suggests that meticulous evaluation of risk factors associated with LNM is required in order to guide the surgical treatment of PTMC patients in clinical practice.

Association of the Preoperative Inflammation-Based Scores with TNM Stage and Recurrence in Patients with Papillary Thyroid Carcinoma: A Retrospective, Multicenter Analysis

Background

The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and prognostic nutritional index (PNI) have been reported to be prognostic biomarkers in various cancers. Our study evaluated whether the preoperative NLR, PLR and PNI predicted tumor-node-metastasis (TNM) stage and recurrence in papillary thyroid carcinoma (PTC) patients.

Methods

A total of 1873 patients with PTC from 9 centers in mainland China were retrospectively assessed. Receiver operating characteristic (ROC) curves were generated, and Kaplan-Meier analyses were performed to evaluate the prognostic value of inflammation-based scores. Univariate and multivariate analyses were conducted to identify risk factors for recurrence.

Results

A decreased PNI and an increased PLR were predictive of TNM stage (p=0.005 and p=0.030, respectively), while a decreased NLR was predictive of recurrence (p=0.040). Univariate and multivariate analyses indicated that N1 status (odds ratio (OR), 1.898; 95% confidence interval (CI), 1.253–2.874; p=0.002), NLR≤1.6 (OR, 1.596; 95% CI, 1.207–2.111; p=0.001) and PNI≤53.1 (OR, 1.511; 95% CI, 1.136–2.009; p=0.005) were independent factors that predicted recurrence.

Conclusion

The NLR, PLR and PNI have predictive value for TNM stage and recurrence in patients with PTC, but their predictive efficiency is limited. Caution should be used when considering clinical applications of inflammation-based scores.

Risk Factors of Deterioration in Quality of Life Scores in Thyroid Cancer Patients After Thyroidectomy

Objective

Despite the expectation of normal life expectancy for thyroid cancer, there are concerns about the decreased quality of life (QoL). The present study investigated the potential risk factors of deterioration in QoL scores in thyroid cancer patients after thyroidectomy.

Materials and methods

A total of 286 patients who were diagnosed with thyroid cancer after thyroidectomy were involved in this prospective, single-center, observational study from November 2018 to June 2019. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 was used to assess the QoL 3 months after thyroidectomy. We investigated the effects of demographics (age, gender, education, marital status, area of residence, and annual mean income), tumor characteristics (histology, clinical stage, presence of metastasis, surgery type, and radiotherapy), and neurological deficits induced by recurrent nerve or superior laryngeal injury on QoL.

Results

The mean overall QoL in thyroid cancer survivors was 65.93 ±9.00 (on a scale of 0–100, where 100 was the best). Multivariate regression analysis confirmed that clinical stage (P < 0.010), surgery type (P < 0.001), histology (P < 0.001), neurological deficits (P < 0.001), and marital status (P < 0.001) were independent risk factors for decreased QoL 3 months after thyroidectomy.

Conclusion

Our study indicated that clinical stage, surgery type, histology, neurological deficits, and marital status were independent risk factors for decreased QoL at 3 months after thyroidectomy. Further exploration and validation of these findings in larger prospective studies are warranted.

Role of pre-operative vitamin D supplementation to reduce post-thyroidectomy hypocalcemia; Cohort study

INTRODUCTION

Hypocalcaemia after thyroidectomy is observed with increasing frequency, often resulting in prolonged hospital stay with increased use of resources, delayed return to work and reduced quality of life. The administration of vitamin D is essential in the therapy of postoperative hypocalcaemia. What has not been examined so far is whether and how routine preoperative vitamin D prophylaxis can help to prevent postoperative hypocalcaemia.

MATERIALS AND METHODS

This is a prospective cohort study which was conducted from June 2016 to July 2017 at a tertiary care hospital. One hundred and two patients with thyroid disease who were admitted for thyroid surgery were interviewed and underwent physical examination and laboratory investigations. The patients enrolled in the study were randomly assigned to either the Interventional group (Pre-operative Vitamin D Supplementation) or the control group (placebo). The work is reported in line with the standards set by STROCCS criteria [1].

RESULTS

Out of 102 patients there were 89 females (87.25%) and 13 males (12.7%) with a mean age of 39.35 ± 7.01 years. In the test group 45 (88.2%) patients had no clinical hypocalcemia, 5 (9.82%) had latent while 1 (2%) patient had overt hypocalcemic symptoms. In placebo group 37 (72.5%) had no clinical hypocalcemia, 10 (19.6%) had latent and 4 (7.8%) had overt hypocalcemic symptoms. (P-value<0.05).

CONCLUSION

As the general population is deficient in Vitamin D, a prophylactic vitamin D dose given in immediate preoperative period can significantly reduce acute symptomatic postoperative hypocalcemia in patients undergoing thyroid surgery.

Coexistent papillary thyroid carcinoma diagnosed in surgically treated patients for primary versus secondary hyperparathyroidism: same incidence, different characteristics

BACKGROUND

The coexistence of hyperparathyroidism and thyroid cancer presents important diagnostic and management challenges. With minimally invasive parathyroid surgery trending, preoperative thyroid imaging becomes more important as concomitant thyroid and parathyroid lesions are reported. The aim of the study was to evaluate the rate of thyroid cancer in patients operated for either primary (PHPT) or secondary hyperparathyroidism (SHPT).

METHODS

Our retrospective study included PHPT and SHPT patients submitted to parathyroidectomy and, when indicated, concomitant thyroid surgery between 2010 and 2017.

RESULTS

Parathyroidectomy was performed in 217 patients: 140 (64.5%) for PHPT and 77 (35.5%) for SHPT. Concomitant thyroid surgery was performed in 75 patients with PHPT (53.6%), and 19 papillary thyroid carcinomas (PTC) were found, accounting for 13.6% from all cases with PHPT and 25.3% from PHPT cases with concomitant thyroid surgery. Thirty-one of operated SHPT patients (40.3%) also underwent thyroid surgery and 9 PTC cases were diagnosed (11.7% of all SHPT patients and 29% of patients with concomitant thyroid surgery). We found differences between PHPT and SHPT patients (p < 0.001) with respect to age (54.6 ± 13y versus 48.8 ± 12y), female-to-male ratio (8:1 versus ~ 1:1), surgical technique (single gland parathyroidectomy in 82.8% PHPT cases; versus subtotal parathyroidectomy in 85.7% SHPT cases) and presurgical PTH (357.51 ± 38.11 pg/ml versus 1020 ± 161.38 pg/ml). Morphopathological particularities, TNM classification and multifocality incidence of PTC were similar in the two groups. All PTC from patients with SHPT were thyroid microcarcinomas (TMC, i.e. tumors with a diameter smaller than 1 cm), whereas seven out of the 19 cases with PTC and PHPT were larger than 1 cm.

CONCLUSIONS

PTC was frequently and similarly associated with both PHPT and SHPT irrespective of presurgical PTH levels. Thyroid tumors above 1 cm were found only in patients with PHPT. Investigators should focus also on associated thyroid nodular pathology in patients with PHPT.

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.

Identification and interaction analysis of key miRNAs in medullary thyroid carcinoma by bioinformatics analysis

Medullary thyroid carcinoma (MTC) is an endocrine tumor and comprises 5–10% of all primary thyroid malignancies. However, the biomechanical contribution to the development and progression of MTC remains unclear. In this study, To discover the key microRNAs (miRNAs or miRs) and their potential roles in the tumorigenesis of MTC, the microarray datasets GSE97070, GSE40807 and GSE27155 were analyzed. The datasets were downloaded from the Gene Expression Omnibus (GEO) database. The differentially expressed miRNAs (DEMs) and genes (DEGs) were accessed by R. Targets of DEMs and predicted using starBase, and functional and pathway enrichment analyses were performed using Metascape. A protein-protein interaction (PPI) network and an analysis of modules were constructed using NetworkAnalyst. Finally, a network was constructed to show the regulatory association between transcription factors (TFs), DEMs and downstream genes. A total of 5 DEMs were found both in GSE97070 and GSE40807, including 3 upregulated DEMs and 2 downregulated DEMs. The Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses from Metascape revealed that the target genes of upregulated DEMs were significantly enriched in adherens junction, kinase and protein binding, while the target genes of downregulated DEMs were mainly involved in non-canonical Wnt signaling pathway and RNA transport. From the PPI network, 13 nodes were screened as hub genes. Pathway enrichment analysis revealed that the top 5 modules were mostly enriched in the neurotrophin signaling pathway, mRNA surveillance pathway and MAPK signaling pathway. In addition, the TF-DEMs-target gene and DEGs regulatory network revealed that 17 TFs regulated 2 miRNAs, including upregulated or downregulated DEMs, CREB1 regulated all upregulated DEMs, and TGFB1 was an activator of hsa-miR-199a-3p and a repressor of hsa-miR-429. Taken together, the present study identified several miRNAs and potential biological mechanisms involved in the tumorigenesis of MTC. This study identified the key DEMs and potential mechanisms underlying the development of MTC, and provided a series of biomarkers and targets for the management of MTC.

Unintentional recurrent laryngeal nerve injuries following thyroidectomy: Is it the surgeon who pays the bill?

BACKGROUND

Thyroidectomy is one of the most common intervention in general surgery and, after the turn of the century, its rate has sharply increased, along with a worldwide increased incidence of differentiated thyroid cancers. Therefore, injuries of the recurrent laryngeal nerve have become one of the most frequent cause of surgical malpractice claims, mostly following surgery for benign pathology.

MAIN BODY

Even if the incidence of definitive paralysis is generally lower than 3%, during the last 20 years in Italy, the number of claims for damages has sharply raised. As a consequence, a lot of defensive medicine has been caused by this issue, and a witch-hunt has been accordingly triggered, so determining mostly a painful and lasting frustration for the surgeons, who sometimes are compelled to pay a lot of money for increasing insurance premiums and lawyers fees. Recurrent laryngeal nerve injury should be considered as a potentially catastrophic predictable but not preventable event, rather than the result of a surgical mistake.

CONCLUSION

Purposes of the Authors are analyzing incidence, conditions of risk, and mechanisms of recurrent laryngeal nerve injuries, underlining notes of surgical technique and defining medical practice recommendations useful to reduce the risk of malpractice lawsuits and judgments against surgeons.

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

Background

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

Main body

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

Conclusions

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

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

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

The prognostic impacts of postoperative radiotherapy in the patients with resected anaplastic thyroid carcinoma: A systematic review and meta-analysis

BACKGROUND

Optimal postoperative managements for anaplastic thyroid carcinoma (ATC) have not yet been sufficiently clarified. We conducted a systematic review and meta-analysis focussing on the impact of postoperative radiotherapy (PORT) in the patients with resected ATC.

MATERIALS AND METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a comprehensive search was performed in the several databases. We included the studies that reported survival outcome in the patients with or without PORT following any type of surgical resection except biopsy only. Hazard ratio (HR) was extracted, and the random-effects model was used for the pooled analysis.

RESULTS

Seventeen retrospective studies including 1147 analysable patients met all inclusion criteria. The overall research quality was relatively low with considerable methodological limitations. The pooled results showed that PORT significantly reduced the risk of death in all the patients with resected ATC compared with those with surgery alone (HR, 0.556; 95% confidence interval, 0.419-0.737; p < 0.001). Exploratory analyses demonstrated that patients with stage IVA (HR, 0.364; p = 0.012) and IVB (HR, 0.460; p = 0.059) may also have survival benefit from PORT, whereas stage IVC may not. No evidence of publication bias was found (p = 0.352).

CONCLUSIONS

This study is the first meta-analysis assessing PORT in patients with ATC and provides convincing evidence that adequate resection followed by PORT may offer the prolonged survival. However, without evidence based on prospective randomised trials, it is still not known which subset of patients can really benefit from PORT.

Changes of Clinicopathologic Characteristics and Survival Outcomes of Anaplastic and Poorly Differentiated Thyroid Carcinoma

BACKGROUND

This study aimed to analyze the temporal changes of the clinicopathologic characteristics, and the long-term outcomes, of various types of anaplastic thyroid cancer (ATC) and poorly differentiated thyroid cancer (PDTC).

METHODS

A retrospective analysis was conducted on patients with ATC and PDTC who were treated from 1985 to 2013. The outcome measures included the clinical response to treatment and the survival rates of three separate thyroid cancer groups: ATC, PDTC, and differentiated thyroid cancer (DTC) with anaplastic foci.

RESULTS

The five-year disease-specific survival rate was significantly higher, both in DTC with anaplastic foci and in PTDC (81.3% and 65.8%, respectively), than it was in ATC (14.3%; p < 0.001). The proportion of cases of DTC with anaplastic foci has been increasing over time, while that of ATC has decreased. The survival rate was found to be significantly higher in resectable tumors (71.4% and 26.5%, respectively; p < 0 .001). In ATC, external beam radiation therapy showed longer survival rates than did surgery-based treatment in unresectable tumors (19.2 vs. 7.7 months, p = 0.006). Adjuvant treatment with external beam radiation or radioactive iodine increased survival duration in PDTC and in DTC with anaplastic foci. Lymphatic invasion was the most significant postoperative prognosticator in ATC (p = 0.013).

CONCLUSIONS

The choice of treatment of ATC and PDTC could be modified according to resectability and lymphatic invasion of the cancer.

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

BACKGROUND

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

METHOD

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

DISCUSSION

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

CONCLUSION

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

The role of surgery in the treatment of thyroid anaplastic carcinoma in the elderly

INTRODUCTION

Anaplastic thyroid carcinoma (ATC) is characterized by local invasiveness, risk of recurrence and very poor prognosis.

METHODS

We retrospectively analysed the multimodality treatment of ATC in 79 patients considering the impact of surgery on survival.

RESULTS

Patients were divided in two age groups A and B (cut-off 75 years) and in two size subgroups (cut-off 5 cm). Surgery was performed in 78.5% patients of group A and 32.4% of B (p < 0.05). Radiation respectively in 73.8% and 43.2% (p < 0.05). Tracheostomy and endoprosthesis were used in 45.2% and 16.6% in group A and in 43.2% and 35.1% in group B. The use of tracheostomy was significantly higher (p < 0.05) in larger tumours. In group B comparing operated and not operated patients significant difference in survival was observed for larger tumours (p = 0.043). In Kaplan Meir analysis significant difference in survival was observed comparing surgical and no surgical patients of all four subgroups. Surgery plus radiotherapy offered a significant better outcome in smaller tumours (p = 0.017). Considering the effect of the single treatment, compared to no treatment at all, survival is significantly improved by surgery for smaller and larger tumours respectively with 4.42 (p = 0.001) and with 3.5 months (p = 0.0001) and by radiotherapy respectively with 3.44 and with 3.28 months (p = 0.047 and p = 0.0001).

CONCLUSION

In elderly patients with ATC, although poor prognosis, surgery is still fundamental in the multimodality treatment with significant advantage in selected patients. Nevertheless most of elderly patients with large tumours are suitable only for palliative management.