Preoperative injection of carbon nanoparticles is beneficial to the patients with thyroid papillary carcinoma: From a prospective study of 102 cases

Application of Carbon Nanoparticles in Transoral Endoscopic Thyroidectomy Vestibular Approach for Unilateral Papillary Thyroid Cancer

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is newly applied technology. Carbon nanoparticles (CNs) are novel lymph node tracers that have been widely used in China to help remove central lymph nodes (CLNs) and protect the parathyroid glands (PGs) in open thyroid cancer surgery. This study is to evaluate the effectiveness and safety of CNs in TOETVA.

MATERIALS AND METHODS

A total of 158 patients who underwent TOETVA with unilateral papillary thyroid carcinoma were enrolled in this study from March 2019 to February 2022. The participants were divided into a CNs group (n=88) and a control group (n=70), based on whether they received a intraoperative injection of CNs or not. Meanwhile, the CNs group were additionally divided into 2 subgroups, leakage subgroup (n=26) and standard subgroup (n=62). The 2 groups and subgroups were compared in terms of patient characteristics, perioperative clinical results, and postoperative outcomes.

RESULTS

All common metrics had no significant differences were found between the CNs group and the control group ( P >0.05). The standard subgroup of CNs group had advantage over the control group on PGs identification (59/62 vs. 59/70 for superior PG, 56/62 vs. 52/70 for inferior PG, P <0.05). Moreover, the standard subgroup harvested more CLNs than the control group (8.97±2.96 vs. 7.47±2.93, P <0.05). More operation time was spent on the leakage subgroup of CNs group than the control group (160.00±17.61 vs. 140.00±13.32, P <0.05). Meanwhile, the leakage subgroup had disadvantage on intraoperative hemorrhage (26.15±10.80 vs. 21.21±7.09, P <0.05) and hospital durations (4.96±0.72 vs. 4.57±0.69, P <0.05). Furthermore, the leakage group identified fewer inferior PG than the control group (7/26 vs. 52/70, P <0.05). Contrary to the standard subgroup, the CLNs of the leakage subgroup was also unsatisfactory compared with the control group (4.96±1.84 vs. 7.47±2.93, P <0.05).

CONCLUSIONS

The application of CNs suspension tracing technology has a definite effect in TOETVA. It can improve the thoroughness of lymph node dissection in the central region and enhance recognition of the PG. However, refined extracapsular anatomy is indispensable to prevent CN leakage. Leaked CNs will also be counterproductive to the operation.

Preoperative application of carbon nanoparticles in transoral endoscopic thyroidectomy vestibular approach for papillary thyroid cancer

Background

Carbon nanoparticles (CNs) have been widely used in the protection of the parathyroid gland and act as a tracer agent in central lymph node dissection. However, the right time for CN injection has not been well illustrated in the transoral endoscopic thyroidectomy vestibular approach (TOETVA). The purpose of this study was to evaluate the safety and feasibility of the preoperative injection of CNs in TOETVA for papillary thyroid cancer.

Methods

From October 2021 to October 2022, a total of 53 consecutive patients with PTC were retrospectively analyzed. All patients underwent unilateral thyroidectomy via the TOETVA. The patients were divided into the preoperative group (n = 28) and the intraoperative group (n = 25) according to CN injection time. In the preoperative group, 0.2 ml of CNs were injected into the thyroid lobules with malignant nodules 1 h before surgery. The numbers of total central lymph node (CLN) and metastatic central lymph node (CLNM), parathyroid autotransplantation, accidental removal of the parathyroid, and the parathyroid hormone level were recorded and analyzed.

Results

The leakage of CNs happened more frequently in the intraoperative group than in the preoperative group (P = 0.002). The mean number of retrieved CLN and CLNM was similar in the preoperative group and the intraoperative group. In parathyroid protection, more parathyroid was discovered in the preoperative group than in the intraoperative group (1.57 ± 0.54 vs. 1.47 ± 0.50, P = 0.002), but less parathyroid autotransplantation (P = 0.004) and accidental removal of the parathyroid (P = 0.036) were discovered in the preoperative group. However, the PTH level between the two groups was similar after the first day and the first month.

Conclusion

The preoperative injection of CNs is a safe and effective method to protect the parathyroid glands (PGs) in patients with PTC undergoing TOETVA. However, the value of preoperative injection of CNs in TOETVA for central lymph node dissection needs to be further studied.

The analysis of risk factors for accidental parathyroid resection during thyroid surgery: a retrospective analysis of 1775 patients

PURPOSE

The present study discussed the effects of accidental parathyroid resection on hypoparathyroidism and investigated the risk factors associated with accidental parathyroid resection.

METHODS

Clinical data from patients who have undergone thyroidectomy at a university hospital in the period from November 2018 and October 2020 were entered into the database and analyzed. Risk factors for accidental parathyroid resection were recorded.

RESULTS

A total of 1775 cases were included in this study. The analysis showed that lymph-node dissection (p < 0.001), T staging (p = 0.037), and treatment group (p < 0.001) were independent risk factors for accidental parathyroid resection. Different treatment groups were important risk factors for accidental parathyroid resection. There were significant differences between the professional and non-professional groups in the following aspects: accidental parathyroid resection (p < 0.001), Scope (p < 0.001), T stage (p = 0.009), N stage (p < 0.001), range of lymph-node dissection (p < 0.001), number of lymph nodes dissected in central area (p < 0.001), and number of lymph-node metastases in the central region (p < 0.001).

CONCLUSIONS

The causes of accidental parathyroid resection are multifactorial. The predictors for accidental parathyroid resection include lymph-node dissection in the central region, T staging, as well as the operating surgeons' experience.

Prophylactic bilateral central neck dissection should be evaluated based on prospective randomized study of 581 PTC patients

BACKGROUND

Prophylactic central lymph node dissection (PCND) was a basic consensus for patients with papillary thyroid carcinoma (PTC) in China. However, unilateral or bilateral central lymph node dissection (CND) was still controversial. This study aimed at investigating the safety and long-term benefit for the patients undergone with bilateral central lymph node dissection (BCCD).

METHODS

581 patients were enrolled and divided randomly into the test and control groups according to range of CND. 285 patients were prospectively assigned to undergo thyroid lobectomy plus BCND in the test group, other 296 patients were assigned to undergo thyroid lobectomy plus ipsilateral central lymph node dissection (ICND) in the control group.

RESULTS

We found that the numbers of total LN and pN1a in the test group were more than that of the control group (p = 0.002,0.004), but there was no difference in the number of metastasized lymph nodes (p = 0.857) and tumor recurrence (p = 0.308). Additionally, in the aspect of postoperative complication (1 day after surgery), the serum levels of parathyroid hormone in the BCND group were lower than that in the ICND group (P = 0.010), and the numbers of transient laryngeal nerve palsy were more than that(p = 0.033). Meanwhile, we further found that pathological tumor size larger than 1 cm and tumor side lymph node metastasis were independent risk factors for contralateral central lymph node metastasis(p = 0.002,0.001).

CONCLUSION

BCND may be an alternative for patients with tumor sizes larger than 1 cm, but it would significantly increase the rate of transient vocal cord palsy, parathyroid auto transplantation and decreased PTH, but the risk of permanent complications was similar to the ICND group.

Preoperative application of carbon nanoparticles in bilateral axillo-breast approach robotic thyroidectomy for papillary thyroid cancer

BACKGROUND

Carbon nanoparticles (CNs) have been used intraoperatively in open thyroid surgery to facilitate central neck dissection and parathyroid protection. However, little attention was paid to the preoperative injection of CNs. Its safety and feasibility remain to be evaluated in bilateral axillo-breast approach robotic thyroidectomy (BABA RT).

METHODS

In this retrospective cohort study, 114 papillary thyroid cancer patients (PTC) undergoing BABA RT were enrolled from March 2020 to March 2021. In the CNs group (n=64), 0.15 mL of CNs was injected into the thyroid lobules with malignant nodules the day before surgery. Medical records were reviewed and analyzed, including complications of CNs usage, surgical outcomes, central lymph node (CLN) retrieval, and parathyroid glands (PGs)-related parameters.

RESULTS

No significant differences were found between the CNs and the control groups in terms of general characteristics and surgical parameters. Complications of CNs were rare in the CNs group. The mean number of retrieved CLN was significantly higher in the CNs group than in the control group (9.48±4.88 vs. 5.40±2.67, P<0.001), as was the mean number of metastatic CLN (2.00±2.56 vs. 1.04±1.70, P=0.018). There were no differences in PGs preserved in situ, PGs autotransplantation, and postoperative PTH levels on the first day and first month (all P>0.05).

CONCLUSIONS

In patients with PTC undergoing BABA RT, preoperative application of CNs is a safe and feasible method to facilitate central neck dissection. However, the value of the preoperative application of CNs in robotic thyroidectomy needs to be further studied because it has no significant benefit for parathyroid protection.

Methods of identification of parathyroid glands in thyroid surgery: A literature review

Intra-operative identification and preservation of parathyroid glands is an important but challenging aspect of thyroid surgery. Failure to do so may lead to transient or permanent hypocalcaemia, where the latter represents a serious complication causing life-long morbidity. It would be beneficial, therefore, if a simple and reliable modality can be developed to assist in the identification of parathyroid glands intra-operatively. The aim of this literature review is to provide an overview of intra-operative modalities used to identify parathyroid glands with a particular focus on near-infrared autofluorescence (NIRAF). Twenty-seven studies were considered relevant in this literature review. Several modalities have been used to aid parathyroid gland identification, including Raman spectroscopy, indocyanine green angiography, and NIRAF. NIRAF technology allows parathyroid glands to spontaneously give off light (autofluorescence) when exposed to near-infrared light at a wavelength of 785 nm, creating a contrast between tissues to allow intra-operative differentiation. Studies utilising NIRAF technology were able to identify 76.3%-100% of parathyroid glands intra-operatively. Furthermore, two randomised controlled trials comparing NIRAF and white light showed that the use of NIRAF was able to significantly increase the mean number of parathyroid glands detected and reduce the incidence of post-operative hypocalcaemia. NIRAF is an emerging tool that has been shown to increase the number of intra-operative parathyroid gland identification and reduce the rate of post-operative hypocalcaemia in a safe and reproducible manner. Future trials are needed to evaluate the real-life impact of NIRAF technology in outcomes of patients following thyroid surgery.

Nanoparticles: Promising Auxiliary Agents for Diagnosis and Therapy of Thyroid Cancers

Simple Summary

Thyroid cancer (TC) is rare relative to cancers of many other organs (breast, prostate, lung, and colon). The majority of TCs are differentiated tumors that are relatively easy to treat and have a good prognosis. However, for anaplastic TC, a rapidly growing and aggressive tumor, treatment is suboptimal because the effective drugs cause severe adverse effects. Drug delivery by nanocarriers can improve treatment by reducing side effects. This can either be mediated through better retention in the tumor tissue due to size (passive targeting) or through the attachment of specific molecules that zero in on the cancer cells (active targeting). Nanoparticles are already used for diagnosis and imaging of TC. For unresectable anaplastic TC, nanoparticle-based treatments, less suitable for deeply located cancers, could be useful, based on low-intensity focused ultrasound and near-infrared irradiation. All potential applications of nanoparticles in TC are still in the preclinical phase.

Abstract

Cancers of the endocrine system are rare. The majority are not highly malignant tumors. Thyroid cancer (TC) is the most common endocrine cancer, with differentiated papillary and follicular tumors occurring more frequently than the more aggressive poorly differentiated and anaplastic TC. Nanoparticles (NP) (mainly mesoporous silica, gold, carbon, or liposomes) have been developed to improve the detection of biomarkers and routine laboratory parameters (e.g., thyroid stimulating hormone, thyroglobulin, and calcitonin), tumor imaging, and drug delivery in TC. The majority of drug-loaded nanocarriers to be used for treatment was developed for anaplastic tumors because current treatments are suboptimal. Further, doxorubicin, sorafenib, and gemcitabine treatment can be improved by nanotherapy due to decreased adverse effects. Selective delivery of retinoic acid to TC cells might improve the re-differentiation of de-differentiated TC. The use of carbon NPs for the prevention of parathyroid damage during TC surgery does not show a clear benefit. Certain technologies less suitable for the treatment of deeply located cancers may have some potential for unresectable anaplastic carcinomas, namely those based on low-intensity focused ultrasound and near-infrared irradiation. Although some of these approaches yielded promising results in animal studies, results from clinical trials are currently lacking.

A simple, efficient, and safe way of finding recurrent laryngeal nerve beneficial for PTC patients

BACKGROUND

More surgeons have known the importance of parathyroid grand and recurrent laryngeal nerve protection in the surgery, but there is still plenty of scope to improve the surgical techniques. This study aims at investigating whether the improved method of finding recurrent laryngeal nerve (RLN) can protect parathyroid grand and RLN.

METHODS

One hundred fifty-eight patients were enrolled and divided randomly into the test and control group according to different methods of finding RLN in the surgery. In the experimental group the author could quickly find the laryngeal recurrent nerve in the lower part of the neck and separate along the surface of the recurrent laryngeal nerve to the point where the recurrent laryngeal nerve gets into the larynx close to the thyroid gland named lateral approach, while in the control group the author severed the middle and lower thyroid vein and raised the lower thyroid pole to look for the RLN near the trachea by the blunt separation.

RESULTS

The author identified 152 and 159 parathyroid glands in the test and control group, respectively and there were a lower ratio of auto-transplantation and less operative time in the test group compared with that in the control group. The author also found that the parathyroid hormone level (1 day and 2 months) in the test group was higher than that in the control group. There were no differences in metastatic LN and recurrent laryngeal nerve palsy in the 2 groups.

CONCLUSION

The improved method of finding RLN is a simple, efficient and safe way, and easy to implement.

Inhibitory effects of miR‑26b‑5p on thyroid cancer

In order to examine the inhibitory effects of microRNA (miR)‑26b‑5p on thyroid cancer (TC), the clinicopathological features and pathological tissues of 67 patients were collected. The expression levels of miR‑26b‑5p were detected in TC and paracarcinoma tissues by quantitative polymerase chain reaction, and the association between miR‑26b‑5p expression and the clinicopathological features of the patients was analyzed using t‑test or one‑way analysis of variance. In addition, B‑CPAP TC cells were infected with a lentivirus to induce miR‑26b‑5p overexpression and proliferation was detected by Cell Counting kit‑8. Subsequently, migration and invasion were detected by Transwell and Matrigel assays, respectively, and the molecular mechanism of action was investigated by western blotting. The results demonstrated that the expression levels of miR‑26b‑5p were significantly lower in TC tissues compared with paracarcinoma tissues (P<0.01), and miR‑26b‑5p was associated with lymph node metastasis (P<0.05). In addition, overexpression of miR‑26b‑5p inhibited the proliferation, invasion and migration of B‑CPAP cells. Western blot analysis demonstrated that the protein expression levels of phosphorylated glycogen synthase kinase‑3β (pGsk‑3β) were decreased, and the expression of β‑catenin was decreased in B‑CPAP cells overexpressing miR‑26b‑5p. These results demonstrated that miR‑26b‑5p may exert antitumor activity. In addition, at the molecular level, these effects may be associated with the Gsk‑3β/β‑catenin pathway.

Application of Carbon Nanoparticles in Endoscopic Thyroidectomy via Bilateral Areola Approach: Total Thyroidectomy Plus Central Lymph Node Dissection

Background: The aim of this report was dual: (a) to describe the step-by-step standardized intraoperative percutaneous injection of carbon nanoparticles (CNPs) procedure for CNP-stained central compartment lymph nodes (CLNs) and passive display of parathyroid gland by CNP-stained thyroid in endoscopic thyroidectomy via bilateral areola approach (ETBAA) and (b) evaluation and outcomes of percutaneous injection of CNPs in total thyroidectomy plus CLN dissection through ETBAA. Materials and Methods: Video describes the technique of intraoperative percutaneous injection of CNPs for central compartment LNs identification, dissection, and parathyroid glands preservation in ETBAA for papillary thyroid cancer. Results: Supplementary video shows that after intrathyroid injection of CNPs, black carbon can be seen rapidly along the lymphatic vessels to the surrounding LNs. Parathyroid gland can be passive display when the thyroid is black and the parathyroid gland is normal in color. Intraoperative neuromonitoring (Medtronic^® NIM-Response 3.0) was applied to identify recurrent laryngeal nerve and external branch of superior laryngeal nerve. No patient had any side effects of CNPs from 152 patients followed up for an average of 19.6 months (6-34 months). LNs were easily found under ETBAA. The accuracy of black-dyed LN in thyroid cancers was 95.9% (1016/1059). The number of parathyroid glands passive display was 69.9% (267/382). Conclusions: It is feasible to use CNPs to show CLNs in thyroid cancer during ETBAA. CNP suspension is safe for thyroidal injection.