Complications after medullary thyroid carcinoma surgery: multicentre study of the SQRTPA and EUROCRINE® databases

SVCT2-targeted PET imaging agent for the evaluation of LN metastasis of thyroid cancer

Cervical lymph node (LN) metastasis is highly prevalent in thyroid cancer (TC). However, the lack of diagnostic modalities that enable real-time assessment of LN metastasis remains a challenge in providing efficient clinical decision-making and optimal patient care. Sodium-ascorbate co-transporters (SVCTs) have shown high expression levels in TC, presenting a potential target for visualizing LN metastasis. In this study, we successfully prepared [18F]FAA, targeting SVCT2, with high radiochemical yield. Subsequently, we demonstrated a significantly high expression of SVCT2 in LN metastasis compared to normal tissues. Then, we demonstrated that [18F]FAA exhibited a significant and specific uptake in TC cells expressing SVCT2. Biodistribution and micro-PET/CT imaging in tumor and lymphadenitis model mice indicated significant [18F]FAA uptake in tumors but not in regions of LN inflammation. Preliminary clinical investigations revealed that [18F]FAA detected a greater number of LN metastatic lesions with higher mean SUVmax and tumor-to-background ratio (TBR) than [18F]FDG. These results highlight the potential of [18F]FAA as a non-invasive imaging agent for accurately detecting LN metastasis in TC.

Thyroidectomy without lymph node dissection should be considered for stage T1 medullary thyroid carcinoma: a population-based cohort study

Background

The necessity and therapeutic value of lymph node dissection (LND) in early stage T1 MTC patients remain controversial.

Methods

Patients with T1MTC were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Poisson regression analysis was utilized to investigate promotive factors for lymph node metastasis in T1MTC patients. Fisher's exact test was employed to calculate baseline differences between non-LND and LND groups. Propensity score match (PSM) was used to control baseline bias. Survival outcomes were calculated by Kaplan-Meier method and log-rank test. Multivariable Cox regression assessed the prognostic impact of LND across subgroups.

Results

Of 3298 MTC cases, 50.4% were T1MTC. The lymph node metastasis rate increased along with the T stage (from 22.2% to 90.5%). Among 1231 T1MTC patients included after exclusion criteria, 72.0% underwent LND and 22.0% had lymph node metastasis. Patients aged younger than 44 years (RR=1.700, p<0.001), male (RR=1.832, p<0.001), and with tumor larger than 10mm (RR=2.361, p<0.001) were more likely to have lymph node metastasis, while elderly patients (p<0.001) and those with microcarcinoma (p<0.001) were more likely to undergo non-LND procedures. LND provided no OS or DSS benefit over non-LND before and after propensity score match (matched 10-year OS/DSS: LND 83.8/96.2% vs non-LND 81.9/99.3%, p>0.05). Subgroup analyses revealed no prognostic gain with LND in any subgroup (p>0.05).

Conclusion

Nearly half of MTC patients were diagnosed at T1 stage and had low lymph node risk. Different from ATA guidelines, avoiding routine LND conferred similar prognosis to standard procedures while potentially improving quality of life. Large-scale prospective multi-center studies should be conducted to further validate these findings.

Risk and Protective Factors of Postoperative and Persistent Hypoparathyroidism after Total Thyroidectomy in a Series of 1965 Patients

BACKGROUND

Postoperative hypoparathyroidism (HypoPTH) is the most common complication following total thyroidectomy. Several risk factors have been identified, but data on postoperative follow-up are scarce.

METHODS

The study focused on 1965 patients undergoing surgery for benign and malignant thyroid diseases at a tertiary-level academic center. Anamnestic, biochemical, surgical, pathological, and follow-up data were evaluated. HypoPTH was defined by a serum concentration of PTH < 10 pg/mL on the first or the second post-operative day. Persistent HypoPTH was defined by the need for calcium/active vitamin D treatment > 12 months after surgery.

RESULTS

Postoperative HypoPTH occurred in 542 patients. Multivariate analysis identified the association of central lymph-nodal dissection, reduced preoperative PTH levels, a lower rate of parathyroid glands preserved in situ, and longer duration of surgery as independent risk factors. At a median follow-up of 47 months, HypoPTH regressed in 443 patients (more than 6 months after surgery in 7%) and persisted in 53 patients. Patients receiving a lower dose of calcium/active vitamin D treatment at discharge (HR 0.559; p < 0.001) or undergoing prolonged, tailored, and direct follow-up by the operating endocrine surgeon team had a significantly lower risk of persistent HypoPTH (2.4% compared to 32.8% for other specialists) (HR 2.563; p < 0.001).

CONCLUSIONS

Various patient, disease, and surgeon-related risk factors may predict postoperative HypoPTH. Lower postoperative calcium/active vitamin D treatment and prolonged, tailored follow-up directly performed by operating endocrine surgeons may significantly reduce the rate of persistent HypoPTH.

Sentinel lymph node detection in thyroid carcinoma using [68Ga]Ga-tilmanocept PET/CT: a proof-of-concept study

PURPOSE

Sentinel lymph node (SLN) biopsy is rarely used for thyroid carcinoma staging. This is due to challenges associated with conventional Tc-99m-labeled tracers, often producing a large hotspot at the injection site, potentially hiding nearby SLNs (shine-through effect). The aim of this study was to demonstrate the feasibility and effectiveness of SLN visualization using the new PET tracer [68Ga]Ga-tilmanocept.

METHODS

Patients with thyroid carcinoma underwent ultrasound-guided peritumoral injection of [68Ga]Ga-tilmanocept and ICG-[99mTc]Tc-nanocolloid. [68Ga]Ga-tilmanocept PET/CT scans were conducted at 15 min and 60 min post-injection to visualize the SLNs. SLN biopsy was performed using ICG-[99mTc]TC-nanocolloid for intraoperative identification. The corresponding lymph node level was resected for reference.

RESULTS

Seven differentiated thyroid carcinoma (DTC) and 3 medullary thyroid carcinoma (MTC) patients were included, of which 6 were clinically node-negative. The median number of SLNs detected on [68Ga]Ga-tilmanocept PET/CT and resected was 3 (range 1-4) and 3 (range 1-5), respectively. Eight SLNs were found on PET/CT in the central compartment and 19 in the lateral compartment. The SLN procedure detected (micro)metastases in all patients except one. Seventeen of 27 pathologically assessed SLNs were positive, 8 negative, and 2 did not contain lymph node tissue, which led to upstaging in 5 out of 6 clinically node-negative patients.

CONCLUSIONS

[68Ga]Ga-tilmanocept PET/CT identified SLNs in all patients, mainly in the lateral neck. The SLNs were successfully surgically detected and resected using ICG-[99mTc]Tc-nanocolloid. This technique has the potential to improve neck staging, enabling more personalized treatment of thyroid cancer according to the lymph node status.

TRIAL REGISTRATION

2021-002470-42 (EudraCT).

The TOFr of 0.75 to 0.85 is the optimal timing for IONM during thyroid surgery: a prospective observational cohort study

BACKGROUD

Recurrent laryngeal nerve (RLN) injury is one of the serious complications of thyroid tumour surgery, surgical treatment of thyroid cancer requires careful consideration of the RLN and its impact on glottis function. There has been no unified standard for precise neuromuscular block monitoring to guide the monitoring of RLN in thyroid surgery. This study aimed to investigate the correlation between Train-of-four stabilization ratio (TOFr) and neural signal values of intraoperative neurophysiological monitoring (INOM) during thyroid operation, and further to determine the optimal timing for INOM during thyroid operation.

METHODS

Patients scheduled for thyroid tumour resection with INOM and RLN monitoring from April 2018 to July 2018 in our center were recruited. Electromyography (EMG) signals and corresponding TOFr were collected. All nerve stimulation data were included in group VR. Vagus nerve stimulation data were included in Subgroup V. RLN stimulation data were included in Subgroup R. The timing of recording was as follows: Vagus nerve EMG amplitude after opening the lateral space between the thyroid and carotid sheath and before the initiation of thyroid dissection, RLN EMG amplitude at first recognition, RLN EMG amplitude after complete thyroid dissection (Repeat three times), and Vagus nerve EMG amplitude after resection of the thyroid (Repeat three times). Correlation analysis of continuous variables was described by a scatter diagram. Pearson correlation analysis or Spearman correlation analysis was used for the two groups of variables.

RESULTS

Finally, 134 vagus nerve signals and 143 RLN signals were analysed after matching with TOFr. The EMG amplitude in the VR group and subgroups after nerve stimulation was positively correlated with TOFr (p < 0.05). In the VR, V and R group, the incidence of EMG ≥ 500 µV in the 0.75 < TOFr ≤ 0.85 interval was significantly higher than the 0 < TOFr ≤ 0.75 interval (P = 0.002, P = 0.013 and P = 0.029), and has no statistical difference compared to 0.85 < TOFr ≤ 0.95 interval (P > 0.05).

CONCLUSIONS

The EMG signals of the RLN and vagus nerve stimulation during thyroid surgery were positively correlated with TOFr. TOFr > 0.75 could reflect more than 50% of the effective nerve electrophysiological signals, 0.75 < TOFr ≤ 0.85 interval was the optimal timing for IONM during thyroid surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR1800015797) Registered on 20/04/2018. https://www.chictr.org.cn .

Incidence of Vocal Cord Paralysis in Medullary Thyroid Cancer

OBJECTIVE

Medullary thyroid cancer (MTC) is a neuroendocrine tumor that comprises 3-5% of all thyroid cancers in the United States. Vocal cord paralysis (VCP) may be due to involvement of the recurrent laryngeal nerve (RLN) preoperatively, or nerve sacrifice during surgery. The purpose of this study was to demonstrate the incidence of VCP in MTC and evaluate whether VCP has an impact on overall survival.

METHODS

This was a retrospective chart review of patients with MTC treated at Loyola University Medical Center from 2007 to 2021. Information on demographics, cancer diagnosis and treatment, laboratory data, and survival were collected.

RESULTS

A total of 79 patients were included in our study. 47 (59.5%) patients were female. The average age at the time of diagnosis was 51.3 years (SD 13.58). VCP was identified in 13 out of 79 (16.5%) patients. There were 71 patients with at least 1-year follow-up with median (Q1, Q3) years of 7.2 (3.9, 11.0). Those with VCP within 1 year had 7.2 (95% CI: 2.3, 22.7) times the risk of death compared to those without (p < 0.001).

CONCLUSION

MTC is a rare thyroid cancer, however, its incidence is on the rise. Our study suggests that the incidence of VCP in these patients appears to be higher than seen in other thyroid malignancies, and VCP is associated with a statistically significant negative impact on survival.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:890-894, 2023.

Hereditary Endocrine Tumor Registries

Context

Endocrine neoplasia syndromes are phenotypically complex, and there is a misconception that they are universally rare. Genetic alterations are increasingly recognized; however, true prevalence is unknown. The purpose of a clinical registry is to monitor the quality of health care delivered to a specified group of patients through the collection, analysis, and reporting of relevant health-related information. This leads to improved clinical practice, decision-making, patient satisfaction, and outcome.

Objective

This review aims to identify, compare, and contrast active registries worldwide that capture data relevant to hereditary endocrine tumors (HETs).

Methods

Clinical registries were identified using a systematic approach from publications (Ovid MEDLINE, EMBASE) peer consultation, clinical trials, and web searches. Inclusion criteria were hereditary endocrine tumors, clinical registries, and English language. Exclusion criteria were institutional audits, absence of clinical data, or inactivity. Details surrounding general characteristics, funding, data fields, collection periods, and entry methods were collated.

Results

Fifteen registries specific for HET were shortlisted with 136 affiliated peer-reviewed manuscripts.

Conclusion

There are few clinical registries specific to HET. Most of these are European, and the data collected are highly variable. Further research into their effectiveness is warranted. We note the absence of an Australian registry for all HET, which would provide potential health and economic gains. This review presents a unique opportunity to harmonize registry data for HET locally and further afield.

Sentinel lymph node detection in thyroid carcinoma using 68Ga-tilmanocept PET/CT: a proof-of-concept study protocol

Sentinel lymph node biopsy (SLNB) is a diagnostic staging procedure. The procedure aims to identify the first draining lymph node(s), which are most likely to contain metastases. SLNB is applied in various cancers, but not currently in thyroid carcinoma. However, treatment strategies are changing, making SLNB clinically relevant. SLNB may lead to more accurate staging, prevent unnecessary treatment and help achieve earlier curation. 68Ga-tilmanocept PET/computed tomography (CT) can better localize sentinel lymph nodes (SLNs) near the primary tumor than planar scintigraphy and single-photon emission computed tomography (SPECT)/CT. This paper describes the rationale and design of a study investigating SLNB using 68Ga-tilmanocept PET/CT and indocyanine-green-99mTc-nanocolloid in ten differentiated and medullary thyroid carcinoma patients. Localization and number of SLNs, pathology result, optimal scan protocol, surgical time and surgeon's experience are examined. Clinical Trial Registration: 2021-002470-42 (EudraCT).

The efficacy and safety of tension-free thyroidectomy in the clinical work of the Endocrine Surgery Department Pavlov State Medical University, pilot study

BACKGROUND: Despite the intensive development of safe thyroid surgery technologies, it has not yet been possible to achieve a significant reduction in the level of specific complications. One of the possible reasons is the method of the conventional surgical operation especially possible traction during thyroid tissue rotation on the way to n.reccurence. In 2022, group of authors led by I.V. Sleptsov proposed a new technique for Tention-Free Thyroidectomy (TFT), which demonstrated a significant reduction in the level of specific complications.

AIM: To conduct a pilot study to assess the reproducibility, efficacy and safety of TFT in the work of the endocrine surgery department of Pavlov First St. Petersburg State Medical University.

MATERIALS AND METHODS: The study was conducted at the Department of Endocrine Surgery in the period from January to April 2022. Patients with surgical thyroid disease underwent a new proposed TFT intervention. The method is fully consistent with the author’s description in patent No. 2772015, and the surgeons performing the new surgical technique underwent an internship with the authors of TFT before the initiation of the study. The study is prospective, non-randomized, uncontrolled. Persistent laryngeal dysfunction and persistent hypoparathyroidism were considered the primary endpoint. Secondary endpoints were transient vocal cord paresis, hypocalcemia and hypoparathyroidism.

RESULTS: The study included 20 people. The indications for surgery were endocrinological and oncological. The number of performed hemithyroidectomies were 15, thyroidectomy (TE) — 5 (one with central lymph node dissection), the volume of the thyroid gland varied from 4 cm3 to 280 cm3 . None of the patients reached the primary endpoint. There were no permanent dysfunction of the larynx in our study. Only in one patient in the postoperative period, a violation of the mobility of the vocal fold was revealed, however, during follow up on the 30th day of the postoperative period the mobility of the vocal fold was restored (confirmed by direct laryngoscopy). Hypoparathyroidism and hypocalcemia were not detected. However, it is necessary to mention the number of TE was too small.

CONCLUSION: Thus, the new proposed TFT method is fully reproducible in the work of a specialized department of endocrine surgery. The method has demonstrated high rates of efficiency and safety in real clinical practice. However, further studies with a higher evidence base are required.

Update on the Diagnosis and Management of Medullary Thyroid Cancer: What Has Changed in Recent Years?

Medullary thyroid carcinoma (MTC) is a neoplasm originating from parafollicular C cells. MTC is a rare disease, but its prognosis is less favorable than that of well-differentiated thyroid cancers. To improve the prognosis of patients with MTC, early diagnosis and prompt therapeutic management are crucial. In the following paper, recent advances in laboratory and imaging diagnostics and also pharmacological and surgical therapies of MTC are discussed. Currently, a thriving direction of development for laboratory diagnostics is immunohistochemistry. The primary imaging modality in the diagnosis of MTC is the ultrasound, but opportunities for development are seen primarily in nuclear medicine techniques. Surgical management is the primary method of treating MTCs. There are numerous publications concerning the stratification of particular lymph node compartments for removal. With the introduction of more effective methods of intraoperative parathyroid identification, the complication rate of surgical treatment may be reduced. The currently used pharmacotherapy is characterized by high toxicity. Moreover, the main limitation of current pharmacotherapy is the development of drug resistance. Currently, there is ongoing research on the use of tyrosine kinase inhibitors (TKIs), highly specific RET inhibitors, radiotherapy and immunotherapy. These new therapies may improve the prognosis of patients with MTCs.

Outcomes of Advanced Medullary Thyroid Carcinoma in the Era of Targeted Therapy

BACKGROUND

Medullary thyroid carcinoma (MTC) can be targeted with tyrosine kinase inhibitors (TKIs). We aimed to report the outcomes of surgically managed MTC and to evaluate the impact of TKI use on patient survival.

METHODS

Consecutive patients treated surgically for MTC from 1986 to 2020 were identified from a prospectively collected database and were compared on the basis of stage at operation and TKI use. The primary outcome was overall survival (OS).

RESULTS

Among 154 patients with a median age of 52 years, 40% presented with stage I/II disease and 60% presented with advanced (stage III or IV) disease. During a median follow-up of 7.5 years, 21% received TKIs for systemic disease. Those presenting with advanced disease were more likely to receive a TKI (31% vs. 7%), present with tumor invasion of the recurrent laryngeal nerve (RLN; 12% vs. 0%) and undergo reoperation (42% vs. 23%) compared with stage I-II patients. For the 11 patients found to have invasion of the RLN, five had preoperative functional vocal cords. Five-year OS was 84% for advanced disease, and stage IV patients who received TKIs had a median survival of 21 years, versus 15 years for those who did not (p = 0.3).

CONCLUSIONS

Surgery achieves long-term survival for patients with advanced disease, however these patients are at greater risk of requiring RLN resection due to invasion. A significant OS benefit was not seen for TKI use. For patients with local invasion, neoadjuvant TKI therapy may have a role in reducing local morbidity if confirmed to be of benefit in clinical trials.