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Iscan Y, Sengun B, Karatas I, Atalay HB, Sormaz IC, Onder S, Yegen G, Hacisahinogullari H, Tunca F, Giles Senyurek Y. The impact of intraoperative neural monitoring during papillary thyroid cancer surgery on completeness of thyroidectomy and thyroglobulin response: a propensity-score matched study. Acta Chir Belg 2024; 124:298-306. [PMID: 38206297 DOI: 10.1080/00015458.2024.2305501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 01/09/2024] [Indexed: 01/12/2024]
Abstract
BACKGROUND Intraoperative neural monitoring (IONM) has been utilized for a variety of thyroid pathologies, including papillary thyroid carcinoma (PTC). Remnant thyroid tissue following total thyroidectomy (TT) in patients with PTC is associated with increased recurrence. The aim of this study is to investigate whether the use of IONM in PTC surgery has an impact on the completeness of thyroidectomy. METHODS Retrospectively, patients with preoperative diagnosis of PTC, who underwent TT in a tertiary center were reviewed. They were grouped based on the IONM usage, and 1:1 propensity-score match was performed. Primary outcome was the completeness of thyroidectomy, determined by measuring postoperative stimulated thyroglobulin levels (sTg). RESULTS Among 274 clinically node-negative PTC patients who underwent TT and ipsilateral prophylactic central lymph-node dissection, a total of 170 patients (85:85) were matched. Postoperative sTg levels were significantly lower in the IONM group (1 ng/dL vs. 0.4 ng/dL; p < 0.01) with higher percentage of the patients with sTg levels <1 ng/ml (50.6% vs. 69.4%; p = 0.01). More patients in the no-IONM group received RAI ablation with significantly higher doses (mean mci: 120 vs. 102; p = 0.02). CONCLUSION The use of IONM during thyroidectomy provides improvement in the completeness of thyroidectomy and reduction in postoperative sTg levels which can be used as a guide by clinicians to avoid RAI ablation in selected PTC patients and to adjust low ablative doses in patients who are scheduled for remnant ablation.
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Affiliation(s)
- Yalin Iscan
- Faculty of Medicine, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Berke Sengun
- Faculty of Medicine, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Irem Karatas
- Faculty of Medicine, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Hasan Berke Atalay
- Faculty of Medicine, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Ismail Cem Sormaz
- Faculty of Medicine, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Semen Onder
- Faculty of Medicine, Department of Pathology, Istanbul University, Istanbul, Turkey
| | - Gulcin Yegen
- Faculty of Medicine, Department of Pathology, Istanbul University, Istanbul, Turkey
| | - Hulya Hacisahinogullari
- Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology, Istanbul University, Istanbul, Turkey
| | - Fatih Tunca
- Faculty of Medicine, Department of General Surgery, Istanbul University, Istanbul, Turkey
| | - Yasemin Giles Senyurek
- Faculty of Medicine, Department of General Surgery, Istanbul University, Istanbul, Turkey
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Giannoula E, Melidis C, Papadopoulos N, Bamidis P, Raftopoulos V, Iakovou I. Dynamic Risk Stratification for Predicting Treatment Response in Differentiated Thyroid Cancer. J Clin Med 2020; 9:E2708. [PMID: 32825789 PMCID: PMC7565378 DOI: 10.3390/jcm9092708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/31/2020] [Accepted: 08/18/2020] [Indexed: 02/07/2023] Open
Abstract
Prognosis in Differentiated Thyroid Cancer (DTC) patients is excellent, but a significant degree of overtreatment still exists because of the inability to accurately identify small patient cohorts who experience a more aggressive form of the disease, often associated with certain poor prognostic factors. Identifying these cohorts at an early stage would allow patients at high risk to receive more aggressive treatment while avoiding unnecessary and invasive treatments in those at low risk. Most risk stratification systems include age, tumor size, grade, presence of local invasion, and regional or distant metastases. Here we discuss these common factors as well as their association with treatment response, but also other upcoming markers including histology and multifocality of primary tumor, dose administered and preparation method for Radioiodine Therapy (RAI), Thyroglobulin (Tg), Anti-thyroglobulin Antibodies (Tg-Ab) levels both at initial management and during follow-up, and the presence of previously existing benign thyroid disease. In addition, we examine the role of remnant size and avidity as well as surgeons' experience in performing thyroidectomies with recurrence rate, discussing its impact on disease prognosis. Our results reveal that treatment response has a statistically significant association with histology, T and M stages, surgeons' experience, Tg levels and remnant score both during RAI and follow up and Tg-Ab levels during follow-up whole body scan (WBS).
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Affiliation(s)
- Evanthia Giannoula
- Second Academic Nuclear Medicine Department, Academic General Hospital of Thessaloniki “AHEPA”, Aristotle University of Thessaloniki, Greece, Kiriakidi 1 St, 54621 Thessaloniki, Greece;
| | - Christos Melidis
- CAP Santé, Radiation Therapy Department, 13 Rue Marcel Paul, 20200 Bastia, France;
| | - Nikitas Papadopoulos
- General Hospital of Thessaloniki “Georgios Gennimatas”, Ethnikis Aminis 41 St, 54635 Thessaloniki, Greece;
| | - Panagiotis Bamidis
- Medical Physics Laboratory, Medical School, Aristotle University of Thessaloniki, 54635 Thessaloniki, Greece;
| | - Vasilios Raftopoulos
- Division of HIV/AIDS Epidemiological Surveillance, National Public Health Organization (E.O.D.Y.), Agrafon 3–5 St, 15123 Athens, Greece;
| | - Ioannis Iakovou
- Second Academic Nuclear Medicine Department, Academic General Hospital of Thessaloniki “AHEPA”, Aristotle University of Thessaloniki, Greece, Kiriakidi 1 St, 54621 Thessaloniki, Greece;
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Patel N, Scott-Coombes D. Impact of surgical volume and surgical outcome assessing registers on the quality of thyroid surgery. Best Pract Res Clin Endocrinol Metab 2019; 33:101317. [PMID: 31526606 DOI: 10.1016/j.beem.2019.101317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The available evidence concerning the relationship between volume and outcome for thyroid surgery is assessed in this article. Morbidity forms the principal surrogate marker of thyroid surgery quality for which postoperative hypocalcaemia and recurrent laryngeal nerve injuries are most commonly reported upon. Whilst there is an abundance of published data for these outcomes, interpretation to recommend annual volume thresholds is challenging. This is due to a lack of consensus on definitions not only for outcomes but high and low volume surgeons. The evidence reviewed in this article supports the notion that high volume surgeons achieve superior outcomes in thyroid surgery quality though it is not possible to recommend minimal annual volumes on the basis of this evidence alone. Every thyroid surgeon should know their own outcomes and how they compare with their peers and engagement in thyroid surgery registries can facilitate this.
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Affiliation(s)
- Neil Patel
- Department of Endocrine and General Surgery, University Hospital of Wales, Heath Park Way, Heath Park, Cardiff, CF14 4XW, UK
| | - David Scott-Coombes
- Department of Endocrine and General Surgery, University Hospital of Wales, Heath Park Way, Heath Park, Cardiff, CF14 4XW, UK.
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Wu SY, Shen HY, Duh QY, Hsieh CB, Yu JC, Shih ML. Routine Intraoperative Neuromonitoring of the Recurrent Laryngeal Nerve to Facilitate Complete Resection and Ensure Safety in Thyroid Cancer Surgery. Am Surg 2018. [DOI: 10.1177/000313481808401232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Routine use of intraoperative neuromonitoring (IONM) in thyroid cancer surgery is controversial. We aimed to investigate whether it improves the completeness of thyroidectomy and ensures safety. This retrospective study included 380 thyroid cancer patients who underwent thyroidectomy, by one surgeon, between July 2006 and November 2015. Patients were grouped according to the surgeon's adaptation of IONM, as follows: none (period 1; n = 92), early (period 2; n = 141), and late (period 3; n = 147). The operative time and rates of vocal cord palsy were determined. Surgical completeness was assessed by technetium-99m imaging of the thyroid remnant and serum thyroglobulin measurement before ablation. The rate of recurrent laryngeal nerve (RLN) palsy showed a decreasing trend over time. No permanent RLN palsies occurred in nerves not invaded by tumor after routine IONM was introduced. Technetium-99m uptake (periods 1–3, 0.62 vs 0.32 vs 0.20; P < 0.01) and thyroglobulin levels (periods 1 and 2, 37.93 vs 8.98 ng/mL, respectively; P = 0.034; period 3, 9.10 ng/mL) progressively decreased. The mean thyroglobulin level dropped significantly after introduction of routine IONM. We conclude that routine IONM during thyroid cancer surgery improves surgical completeness and might prevent permanent RLN palsy over time.
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Affiliation(s)
- Si-Yuan Wu
- Division of General Surgery, Departments of Surgery, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Hung-Yuan Shen
- Nuclear Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, California
| | - Chung-Bao Hsieh
- Division of General Surgery, Departments of Surgery, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Jyh-Cherng Yu
- Division of General Surgery, Departments of Surgery, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Ming-Lang Shih
- Division of General Surgery, Departments of Surgery, National Defense Medical Center, Taipei, Taiwan, R.O.C
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Liu RQ, Wiseman SM. Quality indicators for thyroid cancer surgery: current perspective. Expert Rev Anticancer Ther 2016; 16:919-28. [PMID: 27559618 DOI: 10.1080/14737140.2016.1222274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION While the disease specific mortality of differentiated thyroid cancer has remained low with current treatments, its incidence has been steadily rising over the past several decades, and cancer related recurrence and morbidity have remained a significant problem. Quality indicators currently employed are relevant to the surgical intervention, but do not necessarily reflect oncological outcomes. Therefore, thyroid cancer specific surgical quality indicators, that offer insight into risk of cancer related morbidity and mortality are needed. AREAS COVERED This review aims to discuss the role of measuring quality in thyroid surgical oncology and carry out a comprehensive review of potential quality indicators for thyroid cancer operations. The three quality indicators reviewed here are the postoperative radioactive iodine update by remnant thyroid tissue, the proportion of resected lymph nodes with evidence of metastases, and the post-operative serum thyroglobulin level. Expert commentary: Together, these quality indicators may be utilized to guide improvement of the quality of surgical care for this unique patient population. A critical future step in establishing the role of quality indicators for thyroid cancer surgery is the determination of cutoff values of each indicator in an evidence-based manner.
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Affiliation(s)
- Rachel Q Liu
- a Department of Surgery , St. Paul's Hospital and University of British Columbia , Vancouver , British Columbia, Canada
| | - Sam M Wiseman
- a Department of Surgery , St. Paul's Hospital and University of British Columbia , Vancouver , British Columbia, Canada
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Frangos S, Iakovou IP, Marlowe RJ, Eftychiou N, Patsali L, Vanezi A, Savva A, Mpalaris V, Giannoula EI. Difficulties in deciding whether to ablate patients with putatively "low-intermediate-risk" differentiated thyroid carcinoma: do guidelines mainly apply in the centres that produce them? Results of a retrospective, two-centre quality assurance study. Eur J Nucl Med Mol Imaging 2015; 42:2045-55. [PMID: 26231351 DOI: 10.1007/s00259-015-3124-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 06/29/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE We determined the reasons for radioiodine thyroid remnant ablation, and the procedure's necessity based on postsurgical remnant size, in patients with putatively "low-intermediate-risk" differentiated thyroid carcinoma (DTC). We identified key clinicopathological, treatment and remnant characteristics, and factors associated with remnant size in 336 patients with pT1/2, M0 DTC ablated during the period September 2010 to October 2013 at one Cypriot or one Greek referral centre. METHODS Clinicopathological/treatment characteristics were compiled from charts. Experienced nuclear medicine physicians rated the numbers/intensities of uptake foci in the thyroid bed on postablation planar scintigrams using scales of 0-4 points and 0-3 points, respectively. The product of these scores was taken as the "remnant score" that ranged from 0 (no remnant) to 12 (multiple remnants, intense uptake). RESULTS DTC was predominantly papillary. The median [25th-75th percentile] longest primary tumour diameter was 1.0 cm [0.7-1.5 cm]. Despite favourable histotypes and primary tumour classifications, patients often had preablation characteristics suggesting elevated or uncertain risk: 31.0% of patients (104 of 336) had primary tumour multifocality, 22.0% (74) had confirmed cervical lymph node metastases, 37.2% (125) had unknown nodal status, and 38.1% (128) had antithyroglobulin antibody seropositivity. The median [25th-75th percentile] remnant score was 4 [2-6]; 39.9% of patients (134 of 336) had scores ≥6. For the entire cohort, T or N stages (r ≤ 0.174, P ≤ 0.05) correlated positively with the remnant score in a univariate Spearman analysis. The numbers of patients referred by the surgeon, cervical lymph nodes excised and metastatic nodes excised correlated negatively (r ≤ 0.243, P ≤ 0.038) with the remnant score, and the first two factors independently predicted the remnant score (P ≤ 0.037) in a multivariate analysis. CONCLUSION Patients with putatively "low-intermediate-risk" DTC frequently had disease characteristics denoting high or uncertain risk, suggesting that "selective" radioiodine ablation in such patients may seldom be applicable outside international centres of excellence. Proxies for surgeon experience and surgical completeness correlated with remnant number/uptake intensity and may aid ablation-related decision-making.
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Affiliation(s)
- Savvas Frangos
- Department of Nuclear Medicine, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Strovolos, Nicosia, 2006, Cyprus.
| | - Ioannis P Iakovou
- Department of Nuclear Medicine, Aristotle University, Papageorgiou Hospital, 56403, Thessaloniki, Greece
| | - Robert J Marlowe
- Spencer-Fontayne Corporation, 33 Bentley Avenue, Jersey City, NJ, 07304-1901, USA
| | - Nicolaos Eftychiou
- Department of Nuclear Medicine, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Strovolos, Nicosia, 2006, Cyprus
| | - Loukia Patsali
- Department of Nuclear Medicine, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Strovolos, Nicosia, 2006, Cyprus
| | - Anna Vanezi
- Department of Nuclear Medicine, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Strovolos, Nicosia, 2006, Cyprus
| | - Androulla Savva
- Department of Nuclear Medicine, Bank of Cyprus Oncology Centre, 32 Acropoleos Avenue, Strovolos, Nicosia, 2006, Cyprus
| | - Vassilis Mpalaris
- Department of Nuclear Medicine, Aristotle University, Papageorgiou Hospital, 56403, Thessaloniki, Greece
| | - Evanthia I Giannoula
- Department of Nuclear Medicine, Aristotle University, Papageorgiou Hospital, 56403, Thessaloniki, Greece
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