Extent of thyroidectomy: When should hemithyroidectomy be performed? Recommendations from the Francophone Association for Endocrine Surgery, the French Society of Endocrinology and the French Society of Nuclear Medicine

These recommendations, drawn from current data in the medical literature, incorporate the risks of hemithyroidectomy (HT) and total thyroidectomy (TT) and clarify the place of these two procedures in clinical settings. Discussions leading to a consensus were then assessed by the Francophone Association for Endocrine Surgery (Association francophone de chirurgie endocrinienne [AFCE]), along with the French Society of Endocrinology (Société française d'endocrinologie [SFE]), and the French Society of Nuclear Medicine (Société française de médecine nucléaire [SFMN]). The complication rate was twice as high after TT compared to HT. Total thyroidectomy requires life-long thyroid hormone supplementation, whereas such supplementation is required in only 30% of patients after HT. When surgery is indicated for Bethesda category II nodules, and in the absence of any indication for surgery on the contralateral lobe, HT is recommended. In patients with thyroid cancer (TC)≤1cm requiring surgical management or TC≤2cm, in the absence of risk factors for TC and in the absence of pre- or intraoperative detection of extrathyroidal extension, lymph node metastases (cN0) and/or suspected contra-lateral disease, HT is the preferred technique as long as the patient accepts the possibility of TT which might be required when aggressive forms of cancer are detected on definitive cytohistology (extrathyroidal extension, lymphovascular invasion, high-grade histology). For TC measuring between 2 and 4cm, the debate between HT and TT remains open today, although some surgeons tend to prefer TT. In patients with TC>4cm, macroscopic lymph node involvement (cN1), signs of extrathyroidal extension or predisposing factors for TC, TT is the treatment of choice.

SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Surgical treatment

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French-speaking Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the surgical management of thyroid nodules.

Validating the 'CUT score' risk stratification tool for indeterminate thyroid nodules using the Bethesda system for reporting thyroid cytopathology

PURPOSE

Managing intermediate thyroid nodules remains challenging. The CUT score is an Italian metanalysis-based cytologic (SIAPEC-IAP) scoring system, designed to assist clinicians. However, it was never evaluated against the Bethesda system for reporting thyroid cytopathology (BSRTC). This study aims to validate its utility for BSRTC III and IV nodules in a non-Italian population.

METHODS

We collected all BSRTC III and IV thyroid nodules with a documented final pathology between 2010 and 2020. We calculated the C + U components of the CUT score using retrospective clinical (C) data collection and reevaluation of preoperative sonography (U) examination. The cytology (T) component which originally referred to the five-tiered SIAPEC-IAP cytologic classification was replaced by the corresponding BSRTC categories. Optimal test performances were calculated using receiver operating characteristic (ROC) curve analysis. Data were analyzed twice with considering of NIFTP as benign and as malignant.

RESULTS

After exclusions, 62 nodules from 61 patients were included (50% BSRTC III, 50% BSRTC IV). Malignant nodules demonstrated a significantly higher C + U score compared with benign in both categories. The C + U cutoff value for BSRTC III was 5.25 (sensitivity and specificity of 69.23% and 66.67%, respectively, AUC = 0.72, p-value = 0.016), and 5.75 for BSRTC IV (sensitivity and specificity of 85.7% and 76.5%, respectively, AUC = 0.84, p-value < 0.001).

CONCLUSION

Our study suggests that the CUT score is applicable for both BSRTC III and IV nodules, and highlights the need for internal validations, since the cutoffs found were higher than previously reported.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Utility of Intraoperative Frozen Section in Large Thyroid Nodules

OBJECTIVE

To determine if the routine use of intraoperative frozen section (iFS) results in cost savings among patients with nodules >4 cm with nonmalignant cytology undergoing a thyroid lobectomy.

STUDY DESIGN

Case series with chart review; cost minimization analysis.

SETTING

Single academic center.

SUBJECTS AND METHODS

Records were reviewed on a consecutive sample of 48 patients with thyroid nodules >4 cm and nonmalignant cytology who were undergoing thyroid lobectomy in which iFS was performed between 2010 and 2015. A decision tree model of thyroid lobectomy with iFS was created. Comparative parameters were obtained from the literature. A cost minimization analysis was performed comparing lobectomy with and without iFS and the need for completion thyroidectomy with costs estimated according to 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample.

RESULTS

The overall malignancy rate was 25%, and 33% of these malignancies were identified intraoperatively. When the malignancy rates obtained from our cohort were applied, performing routine iFS was the less costly scenario, resulting in a savings of $486 per case. When the rate of malignancy identified on iFS was adjusted, obtaining iFS remained the less costly scenario as long as the rate of malignancies identified on iFS exceeded 12%. If patients with follicular lesions on cytology were excluded, 50% of malignancies were identified intraoperatively, resulting in a savings of $768 per case.

CONCLUSIONS

For patients with nodules >4 cm who are undergoing a diagnostic lobectomy, the routine use of iFS may result in decreased health care utilization. Additional cost savings could be obtained if iFS is avoided among patients with follicular lesions.

Economic Impact of Frozen Section for Thyroid Nodules with "Suspicious for Malignancy" Cytology

Objective To perform a cost analysis of the routine use of intraoperative frozen section (iFS) among patients undergoing a thyroid lobectomy with "suspicious for malignancy" (SUSP) cytology in the context of the 2015 American Thyroid Association guidelines. Study Design Case series with chart review; cost minimization analysis. Setting Academic. Subjects and Methods Records were reviewed for patients with SUSP cytology who underwent thyroid surgery between 2010 and 2015 in which iFS was utilized. The diagnostic test performance of iFS and the frequency of indicated completion/total thyroidectomies based on the 2015 guidelines were calculated. A cost minimization analysis was performed comparing lobectomy, with and without iFS, and the need for completion thyroidectomy according to costs estimated from 2014 data from Medicare, the Bureau of Labor Statistics, and the Nationwide Inpatient Sample. Results Sixty-five patients met inclusion criteria. The malignancy rate was 61.5%, 45% of which was identified intraoperatively. The specificity and positive predictive value were 100%. The negative predictive value and sensitivity were 83% and 95%, respectively. Completion/total thyroidectomy was indicated for 9% of patients; 83% of these individuals had findings on iFS that would have changed management intraoperatively. Application of the new guidelines would have resulted in a significant reduction in the frequency of conversion to a total thyroidectomy when compared with the actual management (26.1% vs 7.7%, P = .005). Performing routine iFS was the less costly scenario, resulting in a savings of $474 per case. Conclusion For patients with SUSP cytology undergoing lobectomy, routine use of iFS would result in decreased health care utilization.

The futility of intraoperative frozen section in the evaluation of follicular thyroid lesions

OBJECTIVE

Investigate the utility of intraoperative frozen section (iFS) in patients with follicular thyroid lesions following publication of the 2015 American Thyroid Association (ATA) guidelines.

STUDY DESIGN

Retrospective chart review.

METHODS

Patient demographics, preoperative cytology, frozen pathology, and final pathology were reviewed on patients undergoing thyroid surgery at a tertiary care hospital in which iFS was utilized over a 5-year period. The test performance of iFS and the frequency of indicated completion/total thyroidectomies pre- and postpublication of the 2015 ATA guidelines were calculated.

RESULTS

One hundred and one patients met inclusion criteria: 54 patients with follicular lesions of undetermined significance (FLUS) and 47 patients with a cytologic diagnosis of suspicious for follicular neoplasm/follicular neoplasm. The malignancy rate was 36%, but only 14% of malignancies were identified on iFS. A definitive benign or malignant diagnosis was given on iFS in only 21% of cases, and operative management was altered in two cases as a result of iFS. There was a statistically significant reduction in the frequency of indicated total/completion thyroidectomies based on high-risk features as a result of the 2015 ATA guidelines compared to prior recommendations (20.8% vs. 5.0%, P = < 0.001). None of these patients had findings on iFS that would have altered management intraoperatively.

CONCLUSION

Intraoperative frozen section offers minimal diagnostic utility in the evaluation of follicular thyroid lesions. Updates in the 2015 ATA guidelines further diminish its potential to impact management intraoperatively. Significant improvements in its ability to identify malignancies would be needed to justify its use.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1501-1505, 2018.

Management of Childhood Thyroid Nodules: Surgical and Endocrinological Findings in a Large Group of Cases

OBJECTIVE

The management of childhood thyroid nodules is still a big challenge for clinicians. In this study, we aimed to present our surgical and endocrinological experience in more than one hundred pediatric cases.

METHODS

A retrospective analysis of patients admitted with a thyroid nodule between 2006 and 2014 was performed. Detailed ultrasonography and fine-needle aspiration biopsy (FNAB) were the cornerstones of the diagnostic approach.

RESULTS

One hundred-three children (72 female, 31 male) with a mean age of 13.1±3.6 years (3-18 years) were admitted to our center. Management strategy was surgery in 58 patients and follow-up in 45 patients. Mean nodule size was 17±12.7 mm (2-45 mm). The diagnoses were listed as benign solitary nodule (48 patients), thyroid carcinoma (26 patients), multinodular goiter (23 patients), Hashimoto thyroiditis (4 patients), and Graves' disease (2 patients). Surgical procedures were nodulectomy/lobectomy (32 patients), total thyroidectomy (TT) (13 patients), or TT+ neck dissection (13 patients). The rate of malignancy was 25% in the total group and 44% in the surgery group. The malignancy rate was higher in patients younger than 12 years compared to older children (41% vs. 17%, p=0.040). Metastasis was seen in 38% of the malignant nodules. Postoperative complications were transient hypocalcemia (8%), permanent hypocalcemia (1.7%), and unilateral vocal cord paralysis (1.7%). Recurrence or mortality was not encountered in the 5.4±1.2-year follow-up period.

CONCLUSION

Thyroid nodule in a child requires an aggressive diagnostic approach due to increased risk of malignancy and metastasis. Intraoperative frozen section examination must be done as a useful adjunct to determine the surgical strategy. Incidence of complications is small in thyroid surgery when performed by experienced surgeons.

False-positive cytopathology results for papillary thyroid carcinoma: A trap for thyroid surgeons

OBJECTIVES

Current preoperative diagnosis of thyroid nodules remains imperfect despite recent advances in cytopathology and molecular diagnostics. False positivity in preoperative fine-needle aspiration cytology (FNAC) may lead to overtreatment of patients, including total thyroidectomy, and sometimes to lawsuits for misdiagnosis and malpractice. In this study, we analysed clinical characteristics and pathologic findings in patients with false positivity for papillary thyroid carcinoma (PTC) in FNAC.

METHODS

We retrospectively reviewed permanent pathology results from 3788 patients who underwent thyroid surgery. Among them, 48 patients had lesions that were deemed suspicious or positive (Bethesda class V or VI) for PTC in preoperative FNAC. We reviewed clinic-pathologic data, radiologic findings and surgical planning in these patients.

RESULTS

The prevalence of pathologic thyroiditis was significantly higher among patients with false-positive FNAC results than in those with confirmed PTC (54.2% vs 9.2%, P<.001). The analysis of the permanent pathology reports showed that 26 patients had chronic lymphocytic thyroiditis and 22 patients had no evidence of thyroiditis. Among the patients without pathologic thyroiditis, 19 patients (86.4%) had nodular hyperplasia and three (13.6%) had follicular adenoma, while among the patients with pathologic thyroiditis, seven (26.9%) had no nodule, 14 (53.8%) had nodular hyperplasia, two (7.7%) had hyalinized nodules, two (7.7%) had follicular adenoma and one (3.8%) had a hyalinizing trabecular tumour. In 42 patients, the extent of surgery (total thyroidectomy or hemithyroidectomy) was to be determined according to the intra-operative frozen section biopsy results. Among them, four (10.5%) had inconclusive frozen section results, and 38 (90.5%) had benign results on frozen section.

CONCLUSIONS

Patient counselling about the possibility of false positivity is still important. And the presence of thyroiditis might create confusion in the interpretation of cytopathologic results.