Total thyroidectomy without prophylactic central neck dissection in clinically node-negative papillary thyroid cancer: is it an adequate treatment?

Ultrasound radiomics signature for predicting central lymph node metastasis in clinically node-negative papillary thyroid microcarcinoma

BACKGROUND

Whether prophylactic central lymph node dissection is necessary for patients with clinically node-negative (cN0) papillary thyroid microcarcinoma (PTMC) remains controversial. Herein, we aimed to establish an ultrasound (US) radiomics (Rad) score for assessing the probability of central lymph node metastasis (CLNM) in such patients.

METHODS

480 patients (327 in the training cohort, 153 in the validation cohort) who underwent thyroid surgery for cN0 PTMC at two institutions between January 2018 and December 2020 were included. Radiomics features were extracted from the US images. Least absolute shrinkage and selection operator logistic regression were utilized to generate a Rad score. A nomogram consisting of the Rad score and clinical factors was then constructed for the training cohort. Both cohorts assessed model performance using discrimination, calibration, and clinical usefulness.

RESULTS

Based on the six most valuable radiomics features, the Rad score was calculated for each patient. A multivariate analysis revealed that a higher Rad score (P < 0.001), younger age (P = 0.006), and presence of capsule invasion (P = 0.030) were independently associated with CLNM. A nomogram integrating these three factors demonstrated good calibration and promising clinical utility in the training and validation cohorts. The nomogram yielded areas under the curve of 0.795 (95% confidence interval [CI], 0.745-0.846) and 0.774 (95% CI, 0.696-0.852) in the training and validation cohorts, respectively.

CONCLUSIONS

The radiomics nomogram may be a clinically useful tool for the individual prediction of CLNM in patients with cN0 PTMC.

Construction of a nomogram for central lymph node metastasis in papillary thyroid cancer based on gender grouping

BACKGROUND

The status of central lymph nodes is crucial for determining the surgical approach to papillary thyroid carcinoma (PTC). Because of the differences between genders in central lymph node metastasis (CLNM), we aimed to construct separate predictive models for CLNM according to gender.

METHODS

In our study, a total of 1258 PTC patients who underwent thyroid cancer surgery from September 2021 to March 2023 were analyzed retrospectively. The data were analysed univariately and multivariately using SPSS software grouped according to gender and nomograms of CLNM were plotted using R software. The variables included in this study were sex, Age, body mass index, Diabetes, chronic lymphocytic thyroiditis (CLT), Suspicious central lymph node (SCLN), A/T, Margin, Microcalcification (MC), BRAF, Number, Location, CLNM.

RESULTS

The preoperative nomogram in male patients included four clinical variables: CLT, Margin, Number, Size. The preoperative nomogram of female patients included six clinical variables: Age, SCLN, Margin, MC, Number, Size. The calibration curves showed great agreement in both the training group and the validation group. The decision curve analysis showed the feasibility of nomogram in predicting CLNM in both man and woman.

CONCLUSION

Based on the successful establishment of nomogram, we can analyze the variability of CLNM between male and female, which may provide clinicians with personalized clinical schemes in the treatment of PTC.

Gene mutations as predictors of central lymph mode metastasis in cN0 PTC: A meta-analysis

Gene mutations could predict the tumor progression and prognosis, which are us to predict CLNM in patients with cN0 PTC, however, these results are not consistent. This meta-analysis tried to identify gene mutations which could predict CLNM in patients with cN0 PTC. A systematic search was performed for identifying relevant literature published prior to July 2023 in three search engines: PubMed, EMBASE and Web of Science. Studies that investigated the gene mutations for CLNM in patients with cN0 PTC were included in our meta-analysis. Sixteen studies, including 6095 cN0 PTC with BRAF mutations were include in our meta-analysis. The prevalence of CLNM in cN0 PTC ranged from 13.7% to 50.6%. The pooled analysis demonstrated that BRAFV600E mutation is significantly associated with CLNM (OR = 2.01, 95% CI: 1.55-2.60, p < 0.001) in PTC and PTMC (OR = 1.70, 95% CI: 0.51-1.81, p < 0.001). Whereas, cN0 PTC with TERT (OR = 1.94, 95% CI: 0.51-7.36, p = 0.33) and KRAS (OR = 0.57, 95% CI: 0.51-1.81, p = 0.34) mutations might not contribute to predict CLNM. Our analysis identified that BRAF mutation was a predictive factor for cN0 PTC, as well as for cN0 PTMC, which could be useful for clinician to accurately choose prophylactic CLND and better manage cN0 PTC.

Prophylactic central neck dissection for cN0 papillary thyroid carcinoma: is there any difference between western countries and China? A systematic review and meta-analysis

Background

Recommendations for the performance of prophylactic central neck dissection (pCND) in patients with clinically node-uninvolved (cN0) papillary thyroid carcinoma (PTC) are not the same. This meta-analysis set out to compare the effectiveness of pCND with total thyroidectomy (TT) in different countries and regions, mainly between western countries and China.

Methods

The electronic databases PubMed, EMBASE, and Cochrane Library were searched for studies published until August 2022. The incidence rate of cervical lymph node metastases (LNMs), locoregional recurrences (LRRs), and postoperative complications were pooled by a random-effects model. Subgroup analyses based on different countries and regions were performed.

Results

Eighteen studies involving 5,346 patients were analyzed. In the subgroup of western countries, patients undergoing pCND with TT had a significantly lower LRR rate [69/1,804, 3.82% vs. 139/2,541, 5.47%; odds ratio (OR) = 0.56; 95% CI 0.37-0.85] and a higher rate of temporary hypoparathyroidism (HPT) (316/1,279, 24.71% vs. 194/1,467, 13.22%; OR = 2.23; 95% CI 1.61-3.08) than that of the TT alone group, while no statistically significant difference was found in the rate of permanent HPT and temporary and permanent recurrent laryngeal nerve (RLN) injury. In the Chinese subgroup, the pCND with TT group had a significantly higher incidence rate of both temporary HPT (87/374, 23.26% vs. 36/324, 11.11%; OR = 2.24; 95% CI 1.32-3.81) and permanent HPT (21/374, 5.61% vs. 4/324, 1.23%; OR = 3.58; 95% CI = 1.24-10.37) than that of the TT alone group, while no significant difference was detected in the rate of LRR and temporary and permanent RLN injury.

Conclusion

Compared with the TT alone for cN0 PTC patients, pCND with TT had a significantly lower LRR rate while having a higher temporary HPT rate in Europe, America, and Australia; however, it showed no significant difference in decreasing LRR rate while having a significantly raised rate of temporary and permanent HPT in China. More population-based results are required to advocate precision medicine in PTC.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022358546.

A LASSO-based model to predict central lymph node metastasis in preoperative patients with cN0 papillary thyroid cancer

Introduction

Central lymph node metastasis (CLNM) is common in papillary thyroid carcinoma (PTC). Prophylactic central lymph node dissection (PCLND) in clinically negative central compartment lymph node (cN0) PTC patients is still controversial. How to predict CLNM before the operation is very important for surgical decision making.

Methods

In this article, we retrospectively enrolled 243 cN0 PTC patients and gathered data including clinical characteristics, ultrasound (US) characteristics, pathological results of fine-needle aspiration (FNA), thyroid function, eight gene mutations, and immunoenzymatic results. Least absolute shrinkage and selection operator (LASSO) analysis was used for data dimensionality reduction and feature analysis.

Results

According to the results, the important predictors of CLNM were identified. Multivariable logistic regression analysis was used to establish a new nomogram prediction model. The receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) curve were used to evaluate the performance of the new prediction model.

Discussion

The new nomogram prediction model was a reasonable and reliable model for predicting CLNM in cN0 PTC patients, but further validation is warranted.

The clinical significance of the features of the morphological study and immunohistochemical determination of pancytokeratin in the lymph nodes of the central zone in papillary thyroid cancer

Introduction. papillary thyroid cancer is increasingly being detected at early stages when regional and distant metastases are absent per clinical examination. However, lymph nodes of the central zone can carry hidden metastases. frequency of such metastases is 22.3–46.7 %. maximally accurate identification of hidden metastases after lymph node dissection remains an important problem.

Aim. тo evaluate the effect of histological examination characteristics and immunohistochemical measurement of pancytokeratin level on frequency of detection of papillary cancer hidden metastases in regional lymph nodes of the central zone in patients with clinical stage N0 papillary cancer.

Materials and methods. The main group included 50 patients with stage ст1–2N0М0 primary papillary thyroid cancer. Dissected central lymph nodes of the patients prior to formalin fixation were extracted from the sample and inserted in individual paraffin blocks. Apart from standard histological examination, pancytokeratin level was measured immunohistochemically in the lymph nodes. The control group consisted of 200 patients for whom dissected central cell tissue was sectioned into blocks after formalin fixation. The number of lymph nodes in the dissected sample was measured by a pathomorphologist.

Results. In the main group, the number of lymph nodes in the sample varied between 6 and 37 with mean of 20.7 ± 6.8; in the control group the number was lower: 3–25, mean 9.8 ± 5.1 (р = 0.000). In the main group, hidden metastases were detected more frequently than in the control group: in 30 (60 %) and 68 (34 %) cases, respectively (р = 0.001). In 20 (40 %) patients, immunohistochemical examination showed new metastases. use of this method allowed to detect 1 to 7 additional metastases (mean 2.4 ± 1.5 lymph node lesions).

Conclusion. use of targeted dissection with extraction of lymph nodes led to significant increase in their numbers in the samples, and immunohistochemical examination allowed to detect a large number of hidden metastases in the central lymph nodes.

Risk factors of cervical lymph node metastasis in multifocal papillary thyroid cancer

Introduction

Identifying risk variables for cervical lymph node metastases in multifocality papillary thyroid cancer (MPTC) could assist surgeons in determining whether cervical lymph node dissection would be an appropriate surgical option.

Methods

A retrospective cohort of 2006 patients with papillary thyroid cancer were selected. MPTC (N = 460) was defined as the presence of two or more foci of PTC. The risk factors for central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) in MPTC were investigated by univariate and multivariate analyses, including the following items: age at diagnosis, gender, Hashimoto's thyroiditis, extrathyroidal extension (ETE), maximal axial diameter (MAD) and the sum of axial diameters (SAD) of tumor. In addition, CLNM was used to evaluate LLNM.

Results

The incidence of CLNM and LLNM was 44.57% and 17.17%, respectively. The multivariate analysis demonstrated that gender, extrathyroidal extension (ETE), age, maximal axial diameter (MAD), and the sum of axial diameters (SAD) were related to increased risk for CLNM in MPTC (p < 0.05). The area under the receiver operating characteristic (ROC) curve (AUC) for age at diagnosis of CLNM was 0.647, the cut-off value was 50 years old. Additionally, by multivariate analysis, CLNM, ETE, MAD, and SAD were independent risk factors for LLNM in MPTC (p < 0.05). ROC curve analysis demonstrates that AUC for MAD and SAD diagnosis of LLNM were 0.639 and 0.757, and the cut-off values were 16 and 26 mm, respectively.

Conclusions

MPTC patients who have risk factors for CLNM were advised to perform prophylactic central lymph node dissection (CLND). Additionally, the presence of risk factors for LLNM should be individually evaluated and analyzed for the necessity of lateral lymph node dissection.

An innovative synthetic support for immunocytochemical assessment of cytologically indeterminate (Bethesda III) thyroid nodules

Background

Fine needle aspiration (FNA) is the procedure of choice in the evaluation of thyroid nodules. Nodules with indeterminate cytological categories, Bethesda III and IV, pose challenges in clinical practice and are frequently submitted to diagnostic surgery. CytoFoam Core (CFCS) uses an absorbent foam device inserted into the needle hub to collect the cytological sample aspirated during FNA. Specimen is formalin-fixed and paraffin-embedded.

Aim of the study

Assessing diagnostic efficacy of CFCS, compared to traditional cytology, in re-evaluating thyroid nodules classified as Bethesda III, using post-surgical histology as reference standard.

Method

Retrospective study on 89 patients with a first indeterminate cytological report who were referred to the Department of Endocrinology of Regina Apostolorum Hospital (Albano L. Rome, Italy) for a second FNA. FNA was performed after at least one month under ultrasound guidance with a 23G needle according to the established procedure. During the second procedure, both traditional cytological (TC) smears and a single-pass CFCS specimen were obtained for each patient. On CFCS samples immunocytochemical staining for Galectin-3, HBME-1, and CK-19 was also performed. 51 patients eventually underwent surgery, and their histological diagnoses were compared to the TC and CFCS reports. Four parameters were evaluated: inadequacy rate, rate of persistent indeterminate (Bethesda III and IV) reports, rate of malignancy in persistently indeterminate nodules, and rate of cancer in lesions cytologically classified as malignant.

Results

Non-diagnostic samples were 6 (11.8%) in TC vs 3 (5.9%) in CFCS (p=0.4). Persistent indeterminate samples were 31 (60.8%) in TC vs 19 (37.2%) in CFCS (p=0.01). Rate of malignancy in persistently indeterminate nodules was 8/19 (42.1%) in CFCS vs 9/31 (29%) in TC group (p=0.3). Nine/51 (17.6%) samples were classified as benign by TC vs 21/51 (41.2%) samples by CFCS (p<0.01). All nodules resulted benign at post-surgical evaluation. Five/51 (9.8%) samples were classified as suspicious for malignancy/malignant in TC group against 8/51 (15.7%) samples in CFCS (p=0.5). Post-surgical evaluation confirmed malignancy in all these cases.

Conclusion

CFCS demonstrated greater diagnostic accuracy than TC in repeat FNA assessment of cytologically indeterminate nodules. CFCS increased the conclusive diagnosis rate and decreased the number of cytologically indeterminate cases.

Bilateral and Ipsilateral Central Neck Dissection in Total Thyroidectomy: a Long Term Comparison of Complications

The role of prophylactic central compartment neck dissection (CCND) in total thyroidectomy (TT) is controversial in patients without clinically evident lymph nodes metastasis (cN0) because of association with transient and permanent hypoparathyroidism (HPT) as well as transient and permanent recurrent laryngeal nerve (RLN) injury. Instead of bilateral central neck dissection (bCCND), ipsilateral central compartment neck dissection (iCCND) has recently been proposed as a safer, alternative treatment for selected patients. The aim of this study is to characterize the morbidity that CCND (ipsilateral and bilateral) adds to TT. We enrolled 453 patients: Group A (316 patients) underwent TT alone, Group B (86 patients) underwent TT + iCCND, Group C (51 patients) underwent TT + bCCND. We compared the rates of RLN injury and HPT in three groups and data analysis showed that iCCND was associated with increased rate of transient HPT but not permanent HPT and bCCND was associated with increased rate of transient and permanent HPT, when compared with TT alone. Further studies are needed to evaluate the clear advantages of CCND (both ipsilateral and bilateral), but this should be considered in the context of an higher risk of surgical complications (especially transient and permanent hypoparathyroidism), in comparison with TT alone.

Is total thyroidectomy with bilateral central neck dissection the only surgery for papillary thyroid carcinoma patients with clinically involved central nodes?

Background

In clinical practice, we often observed that patients who underwent total thyroidectomy due to clinically involved nodal disease (cN1a) actually had less extensive CLNM on final pathology. This study investigates whether total thyroidectomy and therapeutic bilateral CND are necessary for all PTC patients with cN1a.

Methods

This study retrospectively reviewed 899 PTC patients who underwent total thyroidectomy with bilateral CND from January 2012 to June 2017. The patients were divided into two groups according to pre-operative central lymph node (CLN) status: cN0, no suspicious CLNM; cN1a, suspicious CLNM. We compared the clinicopathological features of these two groups.

Results

There was no significant difference in recurrence between cN0 and cN1a groups after a mean follow-up time of 59.1 months. Unilateral cN1a was related to the largest central LN size ≥ 2 mm (OR = 3.67, p < 0.001) and number of CLNM > 5(OR = 2.24, p = 0.006). On the other hand, unilateral cN1a was not associated with an increased risk of contralateral lobe involvement (OR = 1.35, p = 0.364) and contralateral CLNM (OR = 1.31, p = 0.359). Among 106 unilateral cN1a patients, 33 (31.1%) were found to be pN0 or had ≤ 5 metastatic CLNs with the largest node smaller than 2 mm.

Conclusions

Most cN1a patients were in an intermediate risk group for recurrence and required total thyroidectomy. However, lobectomy with CND should have performed in approximately 30% of the cN1a patients. Pre-operative clinical examination, meticulous radiologic evaluation, and intra-operative frozen sections to check the nodal status are prerequisites for this approach.

Integrating BRAFV600E mutation, ultrasonic and clinicopathologic characteristics for predicting the risk of cervical central lymph node metastasis in papillary thyroid carcinoma

Background

The advantages of prophylactic central lymph node dissection (CLND) for clinically node-negative patients remained a great deal of controversies. Our research was aimed to analyze the relationship between cervical central lymph node metastasis (CLNM) and BRAF^V600E mutation, ultrasonic and clinicopathologic characterizes in papillary thyroid carcinoma (PTC).

Methods and materials

In current study, a total of 112 consecutive PTC patients who experienced thyroidectomy plus cervical central neck dissection were included in our research. All PTC were pre-operatively analyzed by ultrasonic features, including tumor size, multifocality or not, tumor location, internal components, echogenicity, microcalcification, margins, orientation, taller than wide shape, and internal vascularity. The presence of clinicopathologic factors, including age, sex, T stage, Hashimoto’s thyroiditis, and BRAF^V600E mutation was then investigated. Univariate and multivariate analysis were conducted to check into the relationship between predictive factors and cervical CLNM in PTC patients, and then a predictive model was also established.

Results

Pathologically, 58.0% (65/112) of the PTC patients harbored cervical CLNM. Univariate and multivariate analysis were conducted to identify age < 55 years, tumor size > 10 mm, microcalcification, non-concomitant Hashimoto’s thyroiditis and BRAF^V600E mutation were predictive factors for cervical CLNM in PTC. The risk score for cervical CLNM in PTC patients was calculated: risk score = 1.284 × (if age < 55 years) + 1.241 × (if tumor size > 10 mm) + 1.143 × (if microcalcification) – 2.097 × (if concomitant Hashimoto’s thyroiditis) + 1.628 × (if BRAF^V600E mutation).

Conclusion

Age < 55 years old, PTC > 10 mm, microcalcification, non-concomitant Hashimoto’s thyroiditis and BRAF^V600E mutation are predictive factors for cervical CLNM. BRAF^V600E mutation by pre-operative US-FNA technology synergized with clinicopathologic and ultrasonic features is expected to guide the appropriate surgical management for PTC patients.

Construction and Validation of a Prediction Model for Identifying Clinical Risk Factors of Lateral Lymph Node Metastasis in Medullary Thyroid Carcinoma

Purpose

Medullary thyroid carcinoma (MTC) is a rare but highly invasive malignancy, especially in terms of cervical lymph node metastasis. However, the role of prophylactic lateral lymph node dissection (LLND) is still controversial. We hereby aim to explore the risk factors of lateral lymph node metastasis (LLNM) in patients with MTC to guide clinical practice.

Patients and Methods

The clinicopathological characteristics of patients with MTC from the Surveillance, Epidemiology, and End Results (SEER) Program and the Second Affiliated Hospital of Chongqing Medical University were reviewed and analyzed. Univariate and multivariate logistics regression analyses were used to screen the risk factors of LLNM in patients with MTC.

Results

Four variables, including male gender, multifocality, extrathyroidal invasion (EI), and large tumor size (all p < 0.05), were identified as potential independent factors of LLNM in patients with MTC. Based on these results, an individualized prediction model was subsequently developed with a satisfied C-index of 0.798, supported by both internal and external validation with a C-index of 0.816 and 0.896, respectively. We also performed the decision curve analysis (DCA) and calibration curve, which indicated a remarkable agreement in our model for predicting the risk of LLNM.

Conclusion

We determined that various clinical characteristics, male gender, multifocality, EI, and large tumor size, were significantly associated with LLNM in patients with MTC. Thus, a validated prediction model utilizing readily available variables was successfully established to help clinicians make individualized clinical decisions on MTC management, especially regarding whether the LLND is necessary for patients with clinical negative lateral lymph node involvement and the frequency of follow-up without LLND.

Risk Factors for Central Lymph Node Metastases and Benefit of Prophylactic Central Lymph Node Dissection in Middle Eastern Patients With cN0 Papillary Thyroid Carcinoma

Background

Prophylactic central lymph node dissection (PCLND) for adult patients with papillary thyroid carcinoma (PTC) is still a matter of debate. Data on incidence, risk and benefits of PCLND in Middle Eastern patients is lacking. Therefore, we aimed to identify the incidence and predictive clinico-pathological and molecular marker of PCLND in adult patients with clinically node negative (cN0) Middle Eastern PTC.

Methods

This retrospective study included 942 adult Middle Eastern patients with cN0 PTC who underwent total thyroidectomy (TT) or TT+PCLND. Clinico-pathological associations of central lymph node metastasis (CLNM) were assessed. Multivariate analysis was performed using logistic regression and Cox proportional hazards model.

Results

213 patients underwent PCLND and 38.0% (81/213) had positive CLNM. Multivariate analysis demonstrated age ≤55 years (Odds Ratio (OR) = 7.38; 95% Confidence Interval (CI) = 1.59 – 34.31; p = 0.0108), tumor bilaterality (OR = 3.01; 95% CI = 1.01 – 9.21; p = 0.0483), lymphovascular invasion (OR = 2.92; 95% CI = 1.18 – 7.23; p = 0.0206) and BRAF mutation (OR = 3.24; 95% CI = 1.41 – 7.49; p = 0.0058) were independent predictors of CLNM in adult PTC. Furthermore, patients who underwent PCLND showed significant association with improved recurrence-free survival (RFS; p = 0.0379). Multivariate analysis demonstrated that PCLND was an independent predictor of improved recurrence-free survival.

Conclusions

cN0 Middle Eastern PTC patients treated with PCLND showed a significantly better prognosis. PCLND was effective in improving RFS in Middle Eastern PTC patients and should be encouraged for patients with potential risk factors for CLNM.

A Proposed Heterogeneous Ensemble Algorithm Model for Predicting Central Lymph Node Metastasis in Papillary Thyroid Cancer

Purpose

To develop a heterogeneous ensemble algorithm model to precisely predict central lymph node metastasis (CLNM), which can provide a reference value on controversial topics of performing prophylactic central lymph node dissection for patients with papillary thyroid cancer (PTC).

Methods

The study included patients with PTC who underwent an initial thyroid resection in a single-center medical institution between January 2014 and December 2018. A total of 18 variables, including clinical features and ultrasound (US) features, were used in the univariate analysis, multivariate analysis, and feature selection and were also used to develop a heterogeneous ensemble model based on five basic machine learning models, including extreme gradient boosting, k-nearest neighbors, random forest, gradient boosting, and AdaBoost. Moreover, a partial dependent plot was used to explain the heterogeneous ensemble model.

Results

The area under the receiver operating characteristic curve of the heterogeneous ensemble algorithm model was 0.67, which is significantly better than that of the basic machine models in predicting CLNM. All machine learning models performed better than US. Based on multivariate analysis and receiver operating characteristic curve analysis, age ≤33 years, tumor size ≥0.8 cm, US-suspected CLNM, and microcalcification were risk factors for CLNM, and anti-thyroid peroxidase antibody and serum thyroglobulin levels were favorable factors for CLNM.

Conclusion

The proposed heterogeneous ensemble algorithm model may be optimal tool to predict CLNM by integrating clinical and US features.

Risk Factor Analysis for Central Lymph Node Metastasis in Papillary Thyroid Microcarcinoma

Purpose

Although the prognosis of papillary thyroid microcarcinoma (PTMC) is excellent, cervical lymph node metastasis (CLNM) is commonly observed in PTMC. This study aimed to investigate the incidence and risk factors for CLNM in PTMC.

Patients and Methods

Altogether, 687 patients with PTMC who initially underwent unilateral thyroidectomy with unilateral central lymph node dissection or bilateral thyroidectomy with bilateral central lymph node dissection between January 2014 and June 2018 at our hospital were included. The patients were divided into two groups: PTMC with CLNM and PTMC with no CLNM. The clinicopathologic characteristics and ultrasound features were compared between the groups. Univariate and multivariate logistic regression analyses were used to identify the risk factors for CLNM.

Results

CLNM was observed in 121/687 (17.6%) patients with PTMC. PTMC patients aged <55 years exhibited a greater incidence of CLNM (87.6% vs 12.4%) than those aged ≥55 years. PTMC patients with CLNM were more likely to have capsular extension (24.0% vs 15.4%) and extension to the adjacent structures (9.9% vs 4.2%). Patients with microcalcification on ultrasound images were more likely to have CLNM (66.1% vs 47.9%). Multivariate logistic regression analysis revealed that microcalcification (odds ratio [OR]: 2.066, 95% confidence interval [CI]: 1.361-3.135, P<0.001), age <55 years (OR: 2.341, 95% CI: 1.309-4.187, P=0.004), capsular invasion (OR: 1.772, 95% CI: 1.082-2.879, P=0.023), and invasion of the adjacent tissues (OR: 2.872, 95% CI: 1.355-4.187, P=0.004) were significant risk factors for CLNM.

Conclusion

Microcalcification, age <55 years, capsular invasion, and invasion of the adjacent tissues were significant risk factors for CLNM in PTMC.

Identification of biomarkers associated with cervical lymph node metastasis in papillary thyroid carcinoma: Evidence from an integrated bioinformatic analysis

Integrated analysis of accumulated data is an effective way to obtain reliable potential diagnostic molecular of cervical lymph node metastases (LNM) in papillary thyroid carcinoma (PTC). The benefits of prophylactic lymph node dissection (PLND) for these clinically node-negative (cN0) patients remained considerable controversies. Hence, elucidation of the mechanisms of LNM and exploration of potential biomarkers and prognostic indicators are essential for accurate diagnosis of LNM in PTC patients. Up to date, advanced microarray and bioinformatics analysis have advanced an understanding of the molecular mechanisms of disease occurrence and development, which are necessary to explore genetic changes and identify potential diagnostic biomarkers. In present study, we performed a comprehensive analysis of the differential expression, biological functions, and interactions of LNM-related genes. Two publicly available microarray datasets GSE60542 and GSE129562 were available from Gene Expression Omnibus (GEO) database. Differentially expressed genes between clinically node-positive (cN1) and cN0 PTC samples were screened by an integrated analysis of multiple gene expression profile after gene reannotation and batch normalization. Our results identified 48 differentially expressed genes (DEGs) genetically associated with LNM in PTC patients. Gene ontology (GO) analyses revealed the changes in the modules were mostly enriched in the regulation of MHC class II receptor activity, the immune receptor activity, and the peptide antigen binding. Kyoto encyclopedia of genes and genomes (KEGG) enrichment analysis of DEGs displayed the intestinal immune network for IgA production, staphylococcus aureus infection, and cell adhesion molecules (CAMs). To screen core genes related to LNM of PTC from the protein-protein interaction network, top 10 hub genes were identified with highest scores. Our results help us understand the exact mechanisms underlying the metastasis of cervical LNM in PTC tissues and pave an avenue for the progress of precise medicine for individual patients.

Effect of Prophylactic Central Lymph Node Dissection on Locoregional Recurrence in Patients with Papillary Thyroid Microcarcinoma

There is a consensus that central compartment lymph node dissection or modified radical lateral neck dissection should be performed in papillary thyroid microcarcinoma (PTMC) patients with lymph node metastases. Prophylactic central lymph node dissection (PCLND) in patients with clinically node-negative (cN0) PTMC to reduce locoregional recurrence (LRR) rate and improve prognosis remains controversial. The present study aimed to analyze the effect of PCLND on LRR and postoperative complications of PTMC in cN0 patients. We reviewed a cohort of patients with cN0 PTMC who underwent surgery between January 1997 and October 2019. The patients were divided into the PCLND and no lymph node dissection (NLND) groups. Kaplan-Meier curves were constructed to estimate 15-year locoregional recurrence-free survival rate of the two groups, and the difference was compared by the log-rank test. Three Cox regression models were performed to evaluate the correlation between PCLND and LRR. All patients underwent thyroidectomy, and 25 patients developed LRR; of whom, 23 underwent PCLND at initial surgery and 2 went without lymph node dissection. Cox regression analysis showed that PCLND had no effect on LRR. Postoperative hematoma and permanent recurrent laryngeal nerve injury did not occur in the NLND group, and their incidences were 0.5% and 0.3% in the PCLND group, respectively. PCLND had no significant correlation with LRR in patients with cN0 PTMC, and the absolute benefit for PTMC was small.

Personalized treatment for differentiated thyroid cancer: current data and new perspectives

More conservative and personalized treatment options have been developed in recent years to face the rising diagnosis of low-risk differentiated thyroid carcinoma (DTC). The present review describes the change towards a more risk-adapted management either in the treatment or in the follow-up of DTC. Particular attention is given to the innovations introduced by the latest guidelines for low-risk tumors, starting from the most appropriate extension of surgery up to the postoperative management. The emerging role of active surveillance for low-risk microcarcinoma is discussed, as well as the development of percutaneous strategies in the setting of malignant thyroid disease. The recent use of approved new systemic target therapies for advanced radioiodine refractory thyroid cancer is reported, together with the description of new compounds in trial. Finally, we provide some considerations to improve the risk evaluation in a presurgical setting, especially related to the rising role of genetics, to enable better risk-based cancer management and personalized treatment choices.

Thyroid Lobectomy for Low to Intermediate Risk Differentiated Thyroid Cancer

Simple Summary

Total thyroidectomy used to be recommended for all thyroid cancers. We now know that some thyroid cancers have a relatively low risk of recurrence. Today, for some of these cancers, depending on the type of tumor, its’ size and other tumor characteristics, a thyroid lobectomy (or hemithyroidectomy) can be performed without increasing the patient’s risk of cancer recurrence. Thyroid lobectomy has the advantages of having less risk of surgical complications and a less frequent need for thyroid hormone replacement therapy. This approach is not optimal for all thyroid cancers, however, and careful tumor and patient selection are necessary. This review explains the rationale and criteria for patient selection for thyroid lobectomy for selected thyroid cancers.

Abstract

Many recent publications and guidelines have promoted a “more is less” approach in terms of treatment for low to intermediate risk differentiated thyroid cancer (DTC), which comprise the vast majority of thyroid cancers: less extensive surgery, less radioactive iodine, less or no thyroid hormone suppression, and less frequent or stringent follow-up. Following this approach, thyroid lobectomy has been proposed as a means of decreasing short- and long-term postoperative morbidity while maintaining an excellent prognosis for tumors meeting specific macroscopic and microscopic criteria. This article will examine the pros and cons of thyroid lobectomy for low to intermediate risk cancers and discuss, in detail, criteria for patient selection and oncological outcomes.

Unilateral Multifocality and Bilaterality Could Be Two Different Multifocal Entities in Patients with Papillary Thyroid Microcarcinoma

OBJECTIVE

Multifocality within an affected lobe (unilateral multifocality) or two lobes (bilaterality) is commonly denoted as multifocality without differentiation. Recently, there has been molecular evidence indicating that unilateral multifocality and bilaterality could be two different entities. However, few studies concerning the comparison between these two different multifocality entities have been reported.

DESIGN

A retrospective cohort study.

METHODS

From 2010 to 2013, in total, 949 consecutive patients with papillary thyroid microcarcinoma (PTMC) were enrolled and further divided into four groups based on multifocality status. Unilateral multifocality and bilaterality were analyzed by binary logistic regression along with other clinicopathological factors.

RESULTS

Unilateral multifocality, instead of bilaterality, was correlated with central neck metastasis (CNM) in both univariate and multivariate analyses. Group IV (unilateral multifocality and bilaterality coexist) had the highest CNM rate. Group III (unilateral multifocality) had a higher CNM rate than group II (bilaterality, single lesion in each lobe), with a significant difference (p = 0.032). Similar lateral neck metastasis tendency was observed among the four groups. In the multivariate analysis, only unilateral multifocality and bilaterality which coexisted were correlated with CNM. Moreover, 9 cases had a recurrence, with the recurrence rate ranking top in group IV (3.6%), second in group III (2.8%), and third in group II (1.2%). The difference was significant (p = 0.021).

CONCLUSION

Unilateral multifocality and bilaterality could be two different multifocal entities in patients with PTMC. Unilateral multifocality serving as a prognostic factor indicated a worse prognosis than bilaterality on neck metastasis. When the two factors coexisted in PTMC, patients had the highest risk of CNM and possibly local recurrence compared with those with either risk factor alone.

Prophylactic Central Lymph Node Dissection Improves Disease-Free Survival in Patients with Intermediate and High Risk Differentiated Thyroid Carcinoma: A Retrospective Analysis on 399 Patients

The role of prophylactic central lymph node dissection (pCLND) in the treatment of differentiated thyroid cancer (DTC) is controversial and still a matter of debate. The primary outcome of our study was to assess whether pCLND is effective in reducing the incidence of recurrent disease, and the secondary goal was to estimate the incidence of postoperative complications in patients who underwent pCLND and to evaluate the prognostic value of occult node metastases. In this retrospective study, we included patients with preoperative diagnosis of DTC and clinically uninvolved lymph nodes (cN0). The patients were divided into two groups, depending on the surgical approach: total thyroidectomy alone (TT group) or total thyroidectomy and pCLND (pCLND group). Three hundred and ninety-nine patients were included in this study, 320 (80.2%) in the TT group and 79 (19.8%) in the pCLND group. There were no significant differences in morbidity among the two groups. Histopathological evaluation demonstrated a similar distribution of aggressive features, especially regarding multicentricity, extrathyroidal extension, and angioinvasivity between the two groups. Occult lymph node metastases were found in 20 (25.3%) patients in the pCLND group. Prophylactic CLND was effective in improving disease-free survival in patients with intermediate and high risk of disease recurrence (p = 0.0392); occult lymph node metastases resulted as a significant negative prognostic factor (p < 0.001).

Positive central lymph-nodes are underdiagnosed in patients with Bethesda V cytology in an endemic goiter region

Background

Fine needle aspiration (FNA) is a significant diagnostic procedure for detecting malignancy in patients with nodular thyroid disease. A high proportion of patients with cytological diagnosed follicular neoplasia (Bethesda IV and V) ultimately have thyroid cancer. The aim of this study was to evaluate the incidence of preoperatively undiagnosed central lymph node metastasis in patients with multinodular goiter (MNG).

Methods

Patients who underwent FNA and were classified as Bethesda IV/V were included. Applying a radical approach, all patients underwent (hemi)thyroidectomy and prophylactic unilateral central neck dissection.

Results

During our study period 2009-2013, 60 patients (19.7%) were classified as Bethesda IV and 21 (6.9%) Bethesda V. Final histopathological results revealed malignancy in 35 (43.2%) of 81 Bethesda IV/V nodules. Of the nodules classified as Bethesda IV, 20 (33.3%) showed malignancy in the final histology. Ten patients (16.7%) had papillary micro-carcinoma (mPTC, <10 mm), 4 (6.6%) PTC and 6 (10%) follicular thyroid cancer. Fifteen of 21 (71.4%) Bethesda V nodules were revealed as PTC of whom seven (33.3%) patients also had lymph-node metastases.

Conclusions

While 33.3% of the patients with PTC, preoperatively classified as Bethesda V, had previously undetected positive lymph-nodes, only one patient with Bethesda IV had lymph-node metastasis.

Effect of prophylactic central neck dissection on the surgical outcomes in papillary thyroid cancer: experience in a single center

PURPOSE

Morbidity due to papillary thyroid carcinoma (PTC) is increased mostly due to lymph node (LN) metastases, which lead to reoperations and complications associated with these operations. The aim is to compare the outcomes of PTC having total thyroidectomy and prophylactic central lymph node dissection (TT + PCND) with patients having total thyroidectomy (TT) alone.

METHODS

This study is a retrospective cohort analysis of 358 PTC patients that were operated by a single surgeon in a single center. Data about the patients were extracted from the medical records.

RESULTS

Of the patient cohort, 258 patients had TT + PCND (42.5 ± 11.3 years) and 100 patients (41.2 ± 11.9 years) had only TT. Total number of LN extracted in the TT + PCND group was 8.1 ± 6.9. The mean number of metastatic LN were 2.2 ± 1.9. Percentage of patients that had RAI were less in the TT + PCND group compared to the TT group. Seven patients (2.7%) in the TT + PCND group and 19 (19.0%) in TT group had recurrent disease (p < 0.0001). Of the complications, only transient hypoparathyroidism was increased in TT + PCND group compared to TT group (26.7% vs 10%, p < 0.0001).

CONCLUSION

TT + PCND performed by an experienced surgeon seems to decrease the number of LN recurrences, and the need for reoperations.

Morbidity and long-term survival in patients with cervical re-exploration for papillary thyroid carcinoma

Background

Papillary thyroid carcinoma (PTC) has a favorable prognosis following one-stage surgical therapy, whereas two-stage resections bear the risk of increased morbidity and possibly impaired prognosis. To further elucidate the value of surgical re-exploration in PTC, a retrospective study was performed.

Methods

The study involved 187 patients with PTC who underwent total thyroidectomy with central lymph node dissection between 2001 and 2011. The number of two-stage surgeries, the rates of recurrent laryngeal nerve paralysis (RLNP) as well as hypocalcemia, and the long-term survival were assessed.

Results

Two-stage surgeries were performed in 43%. No statistically significant difference was seen between the one- and two-stage resection groups regarding the rate of RLNP (transient 5.6% vs. 6.3%, permanent 2.6% vs. 0%) nor for hypocalcemia (transient 25.2% vs. 18.8%, permanent 14.0% vs. 22.5%). The 10-year recurrence-free survival was 95.5% and the 10-year disease-specific survival was 98.9% with no difference between groups.

Conclusion

Even though two-stage surgeries do not lead to a higher incidence of RLNP and hypocalcemia, optimal preoperative and intraoperative diagnostics have to be carried out to reduce the amount of completion surgeries.

Local lymph node recurrence after central neck dissection in papillary thyroid cancers: A meta analysis

BACKGROUND

Prophylactic central neck dissection (CND) at the time of total thyroidectomy (TT) remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma (PTC). This systematic review and meta-analysis was performed to compare the local recurrence between patients who underwent TT plus CND and those who underwent TT alone.

METHODS

The publicly available literature published from January 1990 to October 2017 concerning TT plus prophylactic CND versus TT for PTC was retrieved by searching the national and international online databases. Meta-analysis was performed after the data extraction process.

RESULTS

Twenty-five studies with comparison between TT+CND and TT alone were eligible and included in this meta-analysis. For both PTC and papillary thyroid microcarcinoma (PTMC), the overall recurrence in TT+CND group was significantly lower than that in TT alone group. The central compartment recurrence was significantly higher in TT alone group than TT+CND group (OR=3.41, 95% Cl [2.00∼5.80], P<0.00001), while no significant difference of lateral compartment recurrence was observed between the two groups (OR=1.19, 95%Cl [0.81∼1.77], P=0.38). We compared ipsilateral CND+TT with TT alone and found that the recurrence was not significantly different between the two groups (OR=1.44, 95%Cl [0.74∼2.81], P=0.28). On the other hand, bilateral CND+TT showed significantly low recurrence (OR=2.48, 95%Cl [1.75∼3.53], P<0.00001).

CONCLUSIONS

The addition of CND to TT resulted in a greater reduction in risk of local recurrence than TT alone, especially preventing central neck recurrences. Additionally, we discovered that bilateral CND in patients with PTC>1cm was necessary.

Evaluation of accuracy of one-step nucleic acid amplification (OSNA) in diagnosis of lymph node metastases of papillary thyroid carcinoma. Diagnostic study

BACKGROUND

The incidence of node metastases in papillary thyroid carcinoma (PTC) is high, ranging from 20% to 90%. Prophylactic central lymph node compartment dissection (CLND), suggested from the latest guidelines for high-risk tumors, meets resistance due to the high incidence of postoperative complications. Recently, new molecular biologic techniques, such as One Step Nucleic Acid Amplification (OSNA), have spread widely, allowing to quickly isolate, amplify and quantify mRNA encoding for proteins selectively present in neoplastic cells, as Cytokeratine-19. The aim of this study is to evaluate the application of OSNA to intraoperative diagnosis of node metastases of PTC.

METHODS

We included in the study patients with preoperative diagnosis of PTC; from each patient one or more lymph nodes were collected. To assess OSNA accuracy, each lymph node was divided into two halves: the first one was analysed with histopathological and immunohistochemical examination, whereas the second was studied with OSNA.

RESULTS

Twenty-six lymph nodes from 13 patients were included in the study. Overall, OSNA sensitivity was 87.5%, specificity 94.4%, positive predictive value 87.5%, negative predictive value 94.4% and accuracy 92.8%.

DISCUSSION AND CONCLUSION

OSNA is effective in detecting lymph node metastases of PTC. Considering the high risk of complications in CLND, and the uncertain prognostic value of lymph node metastases of PTC, OSNA seems to be a promising tool to identify intraoperatively patients who may benefit from CLND.

Predictive role of intraoperative clinicopathological features of the central compartment in estimating lymph nodes metastasis status

Background

To explore the feasibility of immediate assessment, which focuses on clinicopathological characteristics of central lymph nodes (LNs) during operation. Moreover, to analyze the predictive effect of various evaluated indicators on the nature, quantities, and ratios of central lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC), to provide the basis for precise individualized central lymph node dissection (LND).

Methods

According to the inclusion and exclusion criteria, 1,271 PTC patients were selected in this cohort study. In the study, the clinical and pathological characteristics of the central LNs were evaluated by the treatment groups during the operation, which had a similar therapeutic experience. The parameters including the texture, volume, maximum/vertical meridian, extracapsular infiltration, adhesion or fusion, and nano-carbon staining status of the central LNs were collected. According to the pathological results after the operation, the nature, quantities, and rate of LNM in the central compartment were counted. The relationship between these parameters and metastatic nature, quantities, and ratios was analyzed and compared.

Results

Univariate analysis showed that when the larger size of LNs (especially the maximum meridian >0.9 cm), extracapsular infiltration, adhesion and fusion being found, A higher possibility of LNM in the central compartment (P<0.05), higher number and ratio of metastasis (P<0.05) might be existed. Moreover, more than two positive LNs were more likely to appear. Maximum/vertical meridian <2 and texture hardness could not indicate metastasis (P>0.05) and higher metastasis ratio (P>0.05), but could only be used as a reference for the existence of metastasis (P<0.05). The number of metastatic LNs dissected by carbon nanoparticles during operation could be increased (P<0.05). However, it has no predictive effect on the nature and rate of LNM (P>0.05). Multivariate analysis showed that larger central LNs, the maximum meridian >0.9 cm, extracapsular infiltration, adhesion, and fusion were independent prognostic factors for central LNM (P<0.05), which could be used as a predictor of the properties of central LNs during operation. At the same time, larger LNs, extracapsular infiltration, adhesion and fusion, and nano-carbon black staining were independent predictors of LNM in the central compartment, which are more than two (P<0.05).

Conclusions

It is practical and feasible to evaluate the clinicopathological features of central LNs immediately during the operation. Intraoperative assessment of central LNs volume, capsular infiltration, maximum/vertical meridian, carbon nano tracking, and adhesion and fusion has predictive effects differently on the nature, quantities, and ratios of central LNM. In order to make an early prediction and advance judgment, surgeons should pay more attention to evaluate clinicopathological features of central LNs during operation, which is conducive to the proper implementation of LND in the central compartment.

Prophylactic Central Neck Dissection for Papillary Thyroid Carcinoma with Clinically Uninvolved Central Neck Lymph Nodes: A Systematic Review and Meta-analysis

BACKGROUND

Central neck dissection and total thyroidectomy are standard treatments for patients with papillary thyroid carcinoma (PTC) with clinically involved central nodes. However, prophylactic central neck dissection (pCND) in patients with clinically uninvolved cN0 has been beneficial in some studies but ineffective in others. We conducted a meta-analysis to evaluate the efficacy and safety of pCND in patients with central neck lymph nodes cN0 PTC.

METHODS

The PubMed, EMBASE, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry were electronically searched for studies published until September 2017. The meta-analysis was conducted to calculate the pooled effect size by using random-effects model. Treatment efficacies were measured by determining locoregional recurrence (LRR). Secondary outcomes included transient recurrent laryngeal nerve (RLN) injury, permanent RLN injury, transient hypocalcemia, and permanent hypocalcemia.

RESULTS

Twenty-three retrospective and prospective cohort studies involving 18,376 patients were reviewed. Patients who underwent pCND had significantly lower LRR (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.48-0.88) but significantly higher incidence rates of transient RLN injury (OR 2.03; 95% CI 1.32-3.13), transient hypocalcemia (OR 2.23; 95% CI 1.84-2.70), and permanent hypocalcemia (OR 2.22; 95% CI 1.58-3.13) than that of no pCND group.

CONCLUSION

Compared with no pCND, pCND significantly reduces LRR but is accompanied by numerous adverse effects. The clinical decision should be made after the shared decision-making process of clinicians and patients.

Does hyperthyroidism worsen prognosis of thyroid carcinoma? A retrospective analysis on 2820 consecutive thyroidectomies

Background

Hyperthyroidism is associated with high incidence of thyroid carcinoma; furthermore, tumors arisen in hyperthyroid tissue show an aggressive behavior. Thyroid Stimulating Hormone (TSH) and Thyroid-stimulating antibodies, present in Graves’s disease, seem to play a key role in carcinogenesis and tumoral growth.

Methods

We retrospectively reviewed our series of patients who underwent thyroidectomy for thyroid carcinoma. We compared pathological features and surgical outcomes of hyperthyroid versus euthyroid patients.

Results

From 2007 to 2015, 909 thyroidectomies were performed at our institution for thyroid cancer: 87 patients were hyperthyroid and 822 euthyroid. We observed, in hyperthyroid patients, a higher rate of transient hypoparathyroidism (28.1% vs 13.2%; p < 0.01) and of node metastases (12.6% vs 6.1%; p = 0.03); also local recurrence rate was higher (5.7% vs 2.5%) even if not statistically significant (p = 0.17). Five-year disease free survival rate was significant lower in the same group (89.1% vs 96.6%; p = 0.03).

Conclusion

Thyroid cancers in hyperthyroid patients have an aggressive behavior, with high incidence of local invasion and a worse prognosis than euthyroid patients. All hyperthyroid patients should undergo a careful evaluation with ultrasound and scintigraphy; in case of suspicious nodules, an aggressive approach, including thyroidectomy and lymphectomy, is justified. In patients with toxic adenoma, thyroid cancer is uncommon, thus a loboisthmectomy can be safely performed.

Trial registration number

Research registry n. 2670 registered 19 June 2017 (retrospectively registered).

Rationality in prophylactic central neck dissection in clinically node-negative (cN0) papillary thyroid carcinoma: Is there anything more to say? A decade experience in a single-center

AIM

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy. Despite its extremely favorable prognosis, cervical lymph node metastases are a common feature of PTC and a known independent risk factor for local recurrence. However, the role of prophylactic central neck dissection (PCND) remains a matter of debate in patients with clinically node-negative (cN0) PTC. To better clarify the current role of PCND in the surgical treatment of PTC, evaluating advantages and disadvantages of PCND and outcome of cN0 PTC patients who have been treated with either total thyroidectomy alone or in combination with PCND. A review of recent literature data is performed.

METHODS

Between January 2000 and December 2015, 186 consecutive patients with cN0 PTC were identified to be included in the present study. 74 of these underwent total thyroidectomy associated with PCND, while 112 patients underwent total thyroidectomy alone. The epidemiological and clinical-pathological data of all patients included were collected at diagnosis and during follow-up.

RESULTS

Overall complication rate was significantly higher in the group of patients undergoing PCND (39.2% vs. 17.8%, p = 0.0006). To be specific, they presented a considerably increased risk of temporary recurrent laryngeal nerve injury (p = 0.009) and of permanent hypothyroidism (p = 0.016). Overall survival and recurrence rates did not differ between those undergoing PCND and those undergoing total thyroidectomy alone (p = 1.000 and p = 0.715, respectively).

CONCLUSIONS

The results of the present study do not support the routine use of PCND in the treatment of cN0 PTC patients.

Advancement of thyroid surgery video recording: A comparison between two full HD head mounted video cameras

BACKGROUND

The aim of this study was to test two different video cameras and recording systems used in thyroid surgery in our Department. This is meant to be an attempt to record the real point of view of the magnified vision of surgeon, so as to make the viewer aware of the difference with the naked eye vision.

MATERIALS AND METHODS

In this retrospective study, we recorded and compared twenty thyroidectomies performed using loupes magnification and microsurgical technique: ten were recorded with GoPro^® 4 Session action cam (commercially available) and ten with our new prototype of head mounted video camera.

RESULTS

Settings were selected before surgery for both cameras. The recording time is about from 1 to 2 h for GoPro^® and from 3 to 5 h for our prototype. The average time of preparation to fit the camera on the surgeon's head and set the functionality is about 5 min for GoPro^® and 7-8 min for the prototype, mostly due to HDMI wiring cable. Videos recorded with the prototype require no further editing, which is mandatory for videos recorded with GoPro^® to highlight the surgical details.

CONCLUSION

the present study showed that our prototype of video camera, compared with GoPro^® 4 Session, guarantees best results in terms of surgical video recording quality, provides to the viewer the exact perspective of the microsurgeon and shows accurately his magnified view through the loupes in thyroid surgery. These recordings are surgical aids for teaching and education and might be a method of self-analysis of surgical technique.

New perspectives in the diagnosis of thyroid follicular lesions

Thyroid nodules are very common, affecting 19%-67% of the adult population. However, about 10% of them harbor a malignant lesion. Consequently, the first aim in their clinical evaluation is to exclude malignancy. Fine-needle aspiration cytology (FNAC) represents the main diagnostic tool for the evaluation of thyroid nodules. However, FNAC has a main diagnostic limit, namely cellular atypias of indeterminate significance, which require surgical excision and histological examination to differentiate benign from malignant lesions. Histology reports show that approximately 80% of these patients harbor a benign lesion. Therefore, in order to reduce unnecessary thyroidectomy, over the last years, the cytological classification of thyroid nodules has been revised and a number of new instrumental and molecular approaches have been proposed. In the present article, we will attempt to summarize the most recent cytological, molecular and echographic strategies to enhance the diagnostic accuracy of preoperative thyroid follicular lesions. In particular, we will discuss the new cytological classifications from the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), the British Thyroid Association-Royal College of Pathologists (PTA-RCPath) and the new Italian Society for Anatomic Pathology and Cytology (SIAPEC 2014. We will review molecular tests evaluated to ameliorate follicular lesion diagnosis as well as the clinical utility of the new echographic Thyroid Imaging Reporting and Data System (TI-RADS) score.

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.

Intraoperative neuromonitoring in thyroid surgery: Is the two-staged thyroidectomy justified?

BACKGROUND

The aim of this study was to evaluate the diagnostic accuracy of intraoperative neuromonitoring (IONM) in predicting postoperative nerve function during thyroid surgery and its consequent ability to assist the surgeon in intraoperative decision making.

MATERIALS AND METHODS

A total of 2365 consecutive patients were submitted to thyroidectomy by the same surgical team. Group A included 1356 patients (2712 nerves at risk) in whom IONM was utilized, and Group B included 1009 patients (2018 nerves at risk) in whom IONM was not utilized.

RESULTS

In Group A, loss of signal (LOS) was observed in 37 patients; there were 29 true positive, 1317 true negative, 8 false positive, and 2 false negative cases. Accuracy was 99.3%, positive predictive value was 78.4%, negative predictive value was 99.8%, sensitivity was 93.6%, and specificity was 99.4%. A total of 29 (2.1%) cases of unilateral paralysis were observed, 23 (1.7%) of which were transient and 6 (0.4%) of which were permanent. Bilateral palsy was observed in two (0.1%) cases requiring a tracheostomy. In Group A, 31 (2.3%) injuries were observed, 25 (1.8%) of which were transient and 6 (0.4%) of which were permanent. In Group B, 26 (2.6%) unilateral paralysis cases were observed, 20 (2%) of which were transient and 6 (0.6%) of which were permanent; bilateral palsy was observed in 2 (0.2%) cases. In Group B, 28 (2.8%) injuries were observed, 21 (2.1%) of which were transient and 7 (0.7%) of which were permanent. Differences between the two groups were not statistically significant.

CONCLUSIONS

Our results show that IONM has a very high sensitivity and negative predictive value, but also good specificity and positive predictive value. For these reasons, in selected patients with LOS, the surgical strategy should be reconsidered. However, patients need to be informed preoperatively about potential strategy changes during the planned bilateral surgery. Future larger and multicenter studies are needed to confirm the benefits of this therapeutic strategy.

Morbidity of central neck dissection for papillary thyroid cancer

Thyroid cancer has a very well-known propensity for nodal involvement, either in the central and lateral neck compartments. Neck dissection addressing the central compartment may be performed with an elective or therapeutic intent, the former concomitantly to a thyroidectomy whereas the latter may be accomplished also as a revision procedure for recurrent disease. In this paper complications of central compartment neck dissection will be described, analyzing separately primary and revision procedures.

Evaluating the effectiveness of prophylactic central neck dissection with total thyroidectomy for cN0 papillary thyroid carcinoma: An updated meta-analysis

BACKGROUND

The effectiveness of prophylactic central neck dissection (pCND) following total thyroidectomy (TT) in patients with clinical node-negative (cN0) papillary thyroid carcinoma (PTC) is still controversial. The aim of this meta-analysis is to evaluate the outcome of pCND and to provide quantitative evidence.

METHOD

A detailed literature search of PubMed, EMBASE, ClinicalTrails.gov and Cochrane Library electronic databases for articles published up to October 2016 was carried out. This meta-analysis was performed by the random method (Mantel-Haenszel) model. Locoregional recurrence (LRR) and surgical complications were analyzed.

RESULTS

Twenty-two studies comparing pCND + TT (combined) and TT alone in cN0 PTC patients were analyzed. A total of 6930 cases were enrolled, including 2381 cases in the combined group and 4009 cases in the TT-alone group. Compared with TT alone, patients in the combined group showed a significantly lower rate of overall LRR (OR = 0.66, 95% CI = 0.48-0.89) and central compartment recurrence (OR = 0.40, 95% CI = 0.22-0.73). There was no statistical difference in the rate of lateral compartment recurrence. However, the combined group showed a significantly higher rate of temporary and permanent hypoparathyroidism (OR = 2.28, 95% CI = 1.92-2.27/OR = 1.84, 95% CI = 1.15-2.95) and temporary recurrent laryngeal nerve injury (LNR) (OR = 1.53, 95% CI = 1.08-2.16). There was no statistical difference in the rate of permanent LNR, hematoma, hemorrhage or wound infection.

CONCLUSIONS

This meta-analysis revealed that pCND with TT was a significantly efficient way to reduce the risk of LRR. However, pCND + TT increased the incidence rate of temporary and permanent hypoparathyroidism and temporary LNR.

Role of prophylactic central neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of regional recurrence

Prophylactic central neck dissection in clinically node-negative patients remains controversial. The aim of this multicenter retrospective study was to determine the rate of metastases in the central neck in clinically node-negative differentiated thyroid cancer patients, to examine the morbidity, and to assess the risk of regional recurrence in patients treated with total thyroidectomy with concomitant bilateral or ipsilateral central neck dissection compared with those undergoing total thyroidectomy alone. 258 consecutive clinically node-negative patients were divided into three groups according to the procedures performed: total thyroidectomy only (group A), total thyroidectomy with concomitant ipsilateral central neck dissection (group B), and total thyroidectomy combined with bilateral central neck dissection (group C). Mean operative time and postoperative stay were shorter in Group A (p < 0.01). The incidence of postoperative transient hypoparathyroidism was lower in Group A (p = 0.03), whereas no differences in the incidence of permanent hypoparathyroidism and nerve palsy were present. Postoperative radioactive iodine administration was higher in group B and particularly C (p = 0.03) compared with group A. There were no statistically significant differences in terms of regional recurrence. Differentiated thyroid cancer has a high rate of central lymph node metastasis even in clinically node-negative patients; in the present study there was no statistically significant difference in the rates of locoregional recurrence between the three modalities of treatment. Total thyroidectomy appears to be an adequate treatment for clinically node-negative differentiated thyroid cancer. Prophylactic central neck dissection might be considered for differentiated thyroid cancer patients with large tumor size or extrathyroidal extension.

Parathyroidectomy for primary hyperparathyroidism in the elderly: experience of a single endocrine surgery center

BACKGROUND

Primary hyperparathyroidism is a common endocrine disease, and its incidence increases with age.

AIMS

Our aim was to retrospectively evaluate the impact of age on patient outcomes following parathyroidectomy for primary hyperparathyroidism.

METHODS

Two-hundred fifty-six consecutive patients undergoing parathyroidectomy with preoperative diagnosis of primary hyperparathyroidism were divided into three groups according to patient age: group A, ≤64 years; group B, 65-74 years; and group C, ≥75 years.

RESULTS

Thyroid disease was associated with the hyperparathyroidism in 44 patients (28.2%) in group A, 34 (44.7%) in B, and 10 (41.7%) in C (p < 0.01). Minimally invasive parathyroidectomy was performed in 104 patients (66.7%) in group A, 35 (46.1%) in B, and 8 (33.3%) in C (p < 0.01). Conversion to bilateral exploration was carried out in five cases in group A (4.6%), three in B (8.3%), and two in C (20%). Multiglandular disease was observed in six patients (3.8%) in group A, seven (9.2%) in B, and five (20.8%) in C (p = 0.012). Mean postoperative stay was similar between groups; no major complications and no cases of mortality occurred.

DISCUSSION

Multiglandular disease is more common in older patients than younger individuals, and minimally invasive approaches are less used in this patient group. Increased surgical risk and paucity of symptoms in these patients sometimes result in a delay in surgical treatment.

CONCLUSIONS

Parathyroidectomy is a safe and effective procedure to perform in elderly patients. Multiglandular disease was found to be more prevalent in older patients, but minimally invasive parathyroidectomy can be performed safely. Surgeons should consider parathyroidectomy in patients with primary hyperparathyroidism regardless of age.

The Effect of Prophylactic Central Neck Dissection on Locoregional Recurrence in Papillary Thyroid Cancer After Total Thyroidectomy: A Systematic Review and Meta-Analysis : pCND for the Locoregional Recurrence of Papillary Thyroid Cancer

BACKGROUND

The use of prophylactic central neck dissection (pCND) for papillary thyroid cancer (PTC) without clinical evidence of nodal metastasis (cN0) remains controversial. This study was designed to examine whether pCND for PTC affected locoregional recurrence (LRR).

METHODS

A systematic review was performed to compare the LRR between patients with PTC who underwent total thyroidectomy (TT) and pCND and those who underwent TT alone. The primary outcome was LRR. Other outcomes, including postoperative radioiodine (RAI) ablation and surgically related complications, were evaluated. A meta-analysis was performed using the random-effects model.

RESULTS

We included 17 studies, which comprised 4437 patients. Patients in the TT+pCND group had a significantly reduced risk of LRR (risk ratio [RR] = 0.66; 95% confidence interval [CI]: 0.49-0.90; P = 0.008). The LRR in the central neck compartment (RR = 0.35; 95% CI 0.18-0.68; P = 0.002) was significantly lower in the TT+pCND group, whereas the LRR in the lateral neck compartment was similar between the two groups. Compared with the TT alone group, patients in the TT+pCND group tended to receive higher RAI (74.6% vs. 59.9%) and experience temporary hypocalcemia (odds ratio [OR] = 2.37; 95% CI 1.89-2.96; P < 0.00001), permanent hypocalcemia (OR = 1.93; 95% CI 1.05-3.57; P = 0.03), and increased overall morbidity (OR = 2.56; 95% CI 1.75-3.74; P < 0.00001).

CONCLUSIONS

This meta-analysis suggested that although pCND reduced the LRR in PTC-specifically in the central neck compartment-it was accompanied by an increased rate of postoperative hypocalcemia. However, the evidence is limited and randomized, controlled trials are needed to clarify this role further.

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.

Effect of the application of prophylactic central compartment lymph node dissectionon radioiodine ablation doses in patients with papillary thyroid carcinoma

BACKGROUND/AIM

The aim of this study was to document the effect of the application of prophylactic central compartment dissection on radioiodine ablation activities for papillary thyroid carcinoma.

MATERIALS AND METHODS

This retrospective study included 452 (383 females, 69 males; mean age = 46.69 years, min-max: 13-71) patients who received ablative radioiodine activity between April 2010 and December 2014. The histopathological reports of thyroidectomy and the administered radioiodine activity were evaluated. Frequencies of prophylactic central compartment dissection according to T stage of the primary tumor, detection rate of lymph node metastases, and its effect on radioiodine ablation activities were calculated.

RESULTS

Prophylactic central compartment dissection was applied for a total of 252 (56%) patients. The T stages of these patients were T1a, T1b, T2, and T3 in 85 (34%), 106 (42%), 41 (16%), and 20 (8%) cases, respectively. The administered radioiodine ablation activity was affected by central compartment lymph node metastases in 112 (44%) patients. While 32 (29%) of these patients had papillary microcarcinoma (T1a), 48 (43%), 20 (18%), and 12 (11%) of them had T1b, T2, and T3 tumors, respectively.

CONCLUSION

The application of prophylactic central compartment dissection affects the radioiodine ablation activity in approximately half of patients. This effect is more prominent in T1 stage tumors.

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.

Association of BRAF V600E Mutation and MicroRNA Expression with Central Lymph Node Metastases in Papillary Thyroid Cancer: A Prospective Study from Four Endocrine Surgery Centers

BACKGROUND

Studies have demonstrated an association of the BRAF(V600E) mutation and microRNA (miR) expression with aggressive clinicopathologic features in papillary thyroid cancer (PTC). Analysis of BRAF(V600E) mutations with miR expression data may improve perioperative decision making for patients with PTC, specifically in identifying patients harboring central lymph node metastases (CLNM).

METHODS

Between January 2012 and June 2013, 237 consecutive patients underwent total thyroidectomy and prophylactic central lymph node dissection (CLND) at four endocrine surgery centers. All tumors were tested for the presence of the BRAF(V600E) mutation and miR-21, miR-146b-3p, miR-146b-5p, miR-204, miR-221, miR-222, and miR-375 expression. Bivariate and multivariable analyses were performed to examine associations between molecular markers and aggressive clinicopathologic features of PTC.

RESULTS

Multivariable logistic regression analysis of all clinicopathologic features found miR-146b-3p and miR-146b-5p to be independent predictors of CLNM, while the presence of BRAF(V600E) almost reached significance. Multivariable logistic regression analysis limited to only predictors available preoperatively (molecular markers, age, sex, and tumor size) found miR-146b-3p, miR-146b-5p, miR-222, and BRAF(V600E) mutation to predict CLNM independently. While BRAF(V600E) was found to be associated with CLNM (48% mutated in node-positive cases vs. 28% mutated in node-negative cases), its positive and negative predictive values (48% and 72%, respectively) limit its clinical utility as a stand-alone marker. In the subgroup analysis focusing on only classical variant of PTC cases (CVPTC), undergoing prophylactic lymph node dissection, multivariable logistic regression analysis found only miR-146b-5p and miR-222 to be independent predictors of CLNM, while BRAF(V600E) was not significantly associated with CLNM.

CONCLUSION

In the patients undergoing prophylactic CLNDs, miR-146b-3p, miR-146b-5p, and miR-222 were found to be predictive of CLNM preoperatively. However, there was significant overlap in expression of these miRs in the two outcome groups. The BRAF(V600E) mutation, while being a marker of CLNM when considering only preoperative variables among all histological subtypes, is likely not a useful stand-alone marker clinically because the difference between node-positive and node-negative cases was small. Furthermore, it lost significance when examining only CVPTC. Overall, our results speak to the concept and interpretation of statistical significance versus actual applicability of molecular markers, raising questions about their clinical usefulness as individual prognostic markers.

Differentiated thyroid cancer: feasibility of loboisthmectomy in an endemic region

AIM

The aim of the present retrospective study was to assess the feasibility of loboisthmectomy for the treatment of differentiated thyroid cancer in a endemic area, evaluating the histopathological features and the results of a case series of 1154 patients.

PATIENTS AND METHODS

The clinical records of 1154 patients submitted to total thyroidectomy in our Department were retrospectively reviewed to analyze the histopathological characters and the results.

RESULTS

In 1044 cases (90.5%) a papillary cancer was observed, in 110 (9.5%) a follicular carcinoma; microcarcinomas were 399 (34.5%). Multifocality was present in 323 cases (28%), in 142 unilateral (12.3%) and in 181 bilateral (15.7%). Thyroiditis coexisted in 472 patients (40.9%), multinodular goiter in 404 (35%), Graves' disease in 48 (4.1%), and multinodular toxic goiter in 38 (3.3%). Complications were: postoperative bleeding in 20 patients (1.7%), transient unilateral vocal cord paralysis in 20 (1.7%) definitive in 10 (0.86%), a transient bilateral paralysis in 1 (0.08%), a transient hypoparathyroidism in 351 (30.4%), and a definitive in 24 (2.07%). Nodal recurrence occurred in 25 patients (2.16%).

CONCLUSIONS

Total thyroidectomy remains the safest treatment in differentiated thyroid cancer, especially if performed in high volume centers in which complications can be minimized. Loboisthmectomy can be a viable and safe alternative in small (< 1 cm) unifocal tumors in patients at low risk. Loboisthmectomy is limited in endemic areas by the association with other thyroid diseases. A correct and detailed information of the patient is essential before planning surgery.