Central Compartment Reoperation for Recurrent/Persistent Differentiated Thyroid Cancer: Patterns of Recurrence, Morbidity, and Prediction of Postoperative Hypocalcemia

Impact of prophylactic central lymph node dissection on the complications and recurrence rates in papillary thyroid carcinoma-An AFCE (French-speaking Association of Endocrine Surgery) multicentre study based on the EUROCRINE® national data

BACKGROUND

Prophylactic central neck dissection (pCND) remains controversial during the initial surgery for preoperative and intraoperative node-negative (cN0) papillary thyroid carcinoma (PTC).

METHODS

Patients undergoing thyroidectomy with or without pCND (Nx) for PTC in nine French surgical departments, registered in the EUROCRINE® national data in France between January 2015 and June 2021, were included in a cohort study. Demographic and clinicopathological characteristics, complications, and recurrence rates were compared using multivariate regression analysis.

RESULTS

A total of 1905 patients with cN0 PTC were enrolled, including 1534 who had undergone pCND and 371 who hadn't (Nx). Of these, 1546 (81.2%) were female, and the median age was 49 years (range: 15-89 years). Patients who had undergone pCND were more likely to have multifocal tumors (n = 524 [34.2%] vs. n = 68 [18.3%], p < .001) and larger tumors (15.3 vs. 10.2 mm, p = .01) than patients with Nx. Of the patients with pCND, 553 (36%) had positive central LN (N1a), with a median of 1 N1 (IQR 0-5). pCND was associated with a higher temporary hypocalcemia rate (n = 25 [8%] vs. n = 15 [4%], p < .001). The rates of permanent hypocalcemia and temporary and permanent recurrent laryngeal nerve (RLN) palsy were not significantly different between the two groups (p > .2). After adjusting for covariates (age, sex, multifocality, and pathological T stage) in a multivariable Cox PH model, the performance of lymph node dissection (pCND vs. no-pCND) was not associated with PTC recurrence (p = .2).

CONCLUSION

pCND in PTC does not reduce recurrence and is associated with a two-fold increase in the incidence of transient hypoparathyroidism. These data should be considered while issuing further guidelines regarding the treatment of patients with cN0 PTC.

Predicting coexisting thyroid cancer with primary hyperparathyroidism in an endemic region of multinodular goiter: evaluating the effectiveness of preoperative inflammatory markers

Purpose

The aim is to examine the efficacy of inflammatory indicators to predict thyroid cancer in patients with primary hyperparathyroidism (PHPT) in an endemic region of nodular goiter.

Methods

The prospective database was reviewed to identify patients operated on with the diagnosis of PHPT and thyroid disease between April 2015 and June 2021. Permanent pathologic reports were used as the gold standard for diagnosis. Detailed imaging data with peripheral blood inflammation indices were analyzed to assess their predictive values for concomitant PHPT with thyroid cancer. Postoperative complications and the duration of hospitalization were also reviewed.

Results

Thyroid malignancy accompanying PHPT was found in 13 patients (26.0%) out of 50 who had concurrent surgery. The analysis regarding inflammatory indexes revealed nothing significant between thyroid cancer and preoperative blood biochemistry (P > 0.05). In the concurrent surgery group, recurrent laryngeal nerve injury was observed in 1 patient (2.0%) and the mean hospital stay was longer.

Conclusion

In endemic regions of nodular thyroid disease, thyroid cancer might accompany PHPT. The value of inflammatory indexes to predict thyroid malignancy in PHPT is controversial and should not be employed in the surgical decision-making process.

Surgical and Biochemical Outcomes in Nerve Monitored Reoperation Surgery for Recurrent Papillary Thyroid Carcinoma

OBJECTIVE

To study the surgical and biochemical outcomes in nerve-monitored reoperation or revision surgery for recurrent thyroid cancers.

STUDY DESIGN

A single-center retrospective study.

SETTING

Tertiary center.

METHODS

We identified patients with recurrent papillary thyroid carcinoma (PTC) who underwent reoperation/revision surgery. Study outcomes were surgical complications frequency, recurrence, distant metastasis, and biological complete response (BCR) by comparing preoperative and postoperative thyroglobulin (Tg) levels.

RESULTS

Out of 227 patients, 33.9% presented for ≥2 reoperation surgeries. Nineteen (8.4%) had permanent preoperative hypoparathyroidism while 22 patients (9.7%) had preoperative vocal cord paralysis (VCP). Following reoperation surgery, there were 12 cases (5.3%) of permanent hypocalcemia and no cases of unexpected postoperative VCP. BCR was achieved in 31 patients (35.2%) with complete Tg data. Mean preoperative Tg was 47.7 ng/mL and was 19.7 ng/mL postoperatively (p = .003). The cervical nodal recurrence rate after final surgery was 7.0% (n = 16).

CONCLUSION

Reoperation surgery for recurrent PTC may help achieve biochemical remission regardless of age or the number of prior surgeries.

Ultrasound-Guided Ethanol Percutaneous Ablation Versus Rescue Surgery in Patients With Locoregional Recurrence of Papillary Thyroid Cancer

OBJECTIVES

Neck recurrence of papillary thyroid cancer (PTC) is frequently detected after initial surgery. The management of these lesions may include rescue surgery (RS) or minimally invasive techniques in selected patients, but comparative studies evaluating the effectiveness and safety of these techniques are lacking. In this paper, we compared ultrasound-guided ethanol ablation (EA) in selected patients to RS in a matched cohort.

METHODS

We retrospectively compared 41 patients and 41 matched PTC patients without known distant metastases, who underwent ultrasound-guided EA or RS (matched reference group), who had 63 and 75 thyroid bed and/or lymph node confirmed PTC recurrences during a median follow-up of 72.8 and 89.6 months, respectively. The primary outcome was time until structural recurrence, compared using Kaplan-Meier survival curves. The secondary outcomes included time until biochemical recurrence, plasma thyroglobulin (Tg) levels, American Thyroid Association (ATA) response-to-therapy categories by the last available observation, and treatment-derived complications in each group.

RESULTS

No significant differences were found between the EA and RS groups for time until structural recurrence (log-rank test, P=0.94). The time until biochemical recurrence was also similar (P=0.51); and the plasma Tg concentration reduction and proportions of patients in the ATA reclassification categories were also similar. A significantly higher proportion of patients in the RS group presented treatment-derived complications (29.27% vs. 9.75%, P<0.05).

CONCLUSION

In this retrospective analysis, the treatment of PTC neck recurrence with EA in selected patients was comparable to RS in a matched reference group for the long-term risk of structural or biochemical relapse, but with a lower risk of treatment-derived complications. These.

RESULTS

support the effectiveness and safety of this minimally invasive technique in the management of selected patients with recurrent PTC.

Role of computed tomography in the evaluation of regional metastasis in well-differentiated thyroid cancer

Background

Accurate neck staging is essential for performing appropriate surgery and avoiding undue morbidity in thyroid cancer. The modality of choice for evaluation is ultrasonography (US), which has limitations, particularly in the central compartment, that can be overcome by adding a computed tomography (CT).

Methods

A total of 314 nodal levels were analyzed in 43 patients with CT, and US; evaluations were done between January 2013 and November 2015. The images were reviewed by two radiologists independently who were blinded to histopathological outcomes. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of US, CT, and US + CT were calculated using histology as the gold standard.

Results

The overall sensitivity, specificity, PPV, and NPV for US, CT, and US + CT were 53.9%, 88.8%, 74.1%, and 76.4%; 81.2%, 68.0%, 60.1%, and 85.9%; and 84.6%, 66.0%, 59.6%, and 87.8%, respectively. The overall accuracy of the US was 75.80%, the CT scan was 72.93%, and the US + CT scan was 72.93%. For the lateral compartment, the sensitivity, specificity, PPV, and NPV for the US, CT, and US + CT were 56.6%, 91.4%, 77.1%, and 80.5%; 80.7%, 70.6%, 58.3%, and 87.8%; and 84.3%, 68.7%, 57.9%, and 89.6%, respectively. The accuracy of the US was 79.67%, the CT scan was 73.98%, and the US + CT scan was 73.98% for the lateral compartment. For the central compartment, the sensitivity, specificity, PPV, and NPV for the US, CT, and US + CT were 47.1%, 76.5%, 66.7%, and 59.1%; 82.4%, 55.9%, 65.1%, and 76.0%; and 85.3%, 52.9%, 64.4%, and 78.3%, respectively. The accuracy of the US was 61.76%, the CT scan was 69.12%, and the US + CT scan was 69.12% for the central compartment.

Conclusions

This study demonstrated that CT has higher sensitivity in detecting nodal metastasis; however, its role is complementary to US due to low specificity.

Recurrent Differentiated Thyroid Cancer: The Current Treatment Options

Differentiated thyroid carcinomas (DTC) have an excellent prognosis, but this is sometimes overshadowed by tumor recurrences following initial treatment (approximately 15% of cases during follow-up), due to unrecognized disease extent at initial diagnosis or a more aggressive tumor biology, which are the usual risk factors. The possible sites of recurrence are local, regional, or distant. Local and regional recurrences can usually be successfully managed with surgery and radioiodine therapy, as are some isolated distant recurrences, such as bone metastases. If these treatments are not possible, other therapeutic options such as external beam radiation therapy or systemic treatments should be considered. Major advances in systemic treatments have led to improved progression-free survival in patients previously considered for palliative treatments; among these treatments, the most promising results have been achieved with tyrosine kinase inhibitors (TKI). This review attempts to give a comprehensive overview of the current treatment options suited for recurrences and the new treatments that are available in cases where salvage surgery is not possible or in cases resistant to radioiodine.

The lymph node yield in the initial lateral neck dissection predicts recurrence in the lateral neck of papillary thyroid carcinoma: a revision surgery cohort study

BACKGROUND

This study aimed to evaluate the relationship between lateral lymph node yield (LLNY) and the ratio of lateral positive lymph nodes to lymph node yield (LPLR) from initial lateral neck dissection (LND) in patients with papillary thyroid carcinoma (PTC), as well as the risk of recurrence in patients undergoing LND reoperations.

METHODS

This retrospective cohort study enrolled patients with PTC who underwent revision LND between 1 January 2012, and 31 December 2021. The initial and revised clinical data were retrieved. Patient demographics, clinicopathological features, clinical records, and follow-up information were also reviewed. LLNY and LPLR were determined during the initial LND.

RESULTS

In total, 156 patients with PTC were included in this study, with a median follow-up of 36.5 months; 107 had recurrent lateral neck disease. The optimal LLNY and LPLR cutoff values for recurrent/persistent disease were 24.5 and 32.74%, respectively. The high-risk group (LLNY<25) had the lowest recurrence-free survival rate compared with to moderate-risk group (LLNY≥25, LPLR≥32.74%) and low-risk group (LLNY≥25, LPLR<32.74%) ( P <0.001). The moderate-risk group had lower recurrence-free survival than the low-risk group. Multivariate analysis revealed that an LLNY less than 25 in the initial LND was an independent risk factor for recurrence/persistence of lateral neck ( P <0.001).

CONCLUSIONS

This study identified that LLNY and LPLR were associated with recurrence/persistence in PTC patients at the time of revision surgery was performed.

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.

The outcomes and prognostic factors of patients who underwent reoperation for persistent/recurrent papillary thyroid carcinoma

BACKGROUND

While the most suitable approach for treating persistent/recurrent papillary thyroid carcinoma (PTC) remains controversial, reoperation may be considered an effective method. The efficacy of reoperation in patients with locoregional persistent/recurrent PTC, especially those with unsatisfactory radioactive iodine (RAI) ablation results, is still uncertain. This study aimed to clarify the clinical management strategies for locoregional persistent/recurrent PTC and to explore factors that may affect long-term patient outcomes after reoperation.

METHODS

In total, 124 patients who initially underwent thyroidectomy and variable extents of RAI therapy and finally received reoperation for locoregionally persistent/recurrent PTC were included. The parameters associated with recurrence-free survival (RFS) were analysed using a Cox proportional hazards model.

RESULTS

Overall, 124 patients presented with structural disease after initial therapy and underwent secondary surgical resection, of whom 32 patients developed further structural disease during follow-up after reoperation. At the time of reoperation, metastatic lymph nodes with extranodal extension (P = 0.023) and high unstimulated thyroglobulin (unstim-Tg) levels after reoperation (post-reop) (P = 0.001) were independent prognostic factors for RFS. Neither RAI avidity nor the frequency and dose of RAI therapies before reoperation affected RFS.

CONCLUSIONS

Reoperation is an ideal clinical treatment strategy for structural locoregional persistent/recurrent PTC, and repeated empirical RAI therapies performed prior to reoperation may not contribute to the long-term outcomes of persistent/recurrent PTC patients. Metastatic lymph nodes with extranodal extension and post-reop unstim-Tg > 10.1 ng/mL may predict a poor prognosis.

Prophylactic central lymph node dissection in differentiated thyroid cancer - benefits and risk

INTRODUCTION

Papillary thyroid cancer is the most common thyroid malignancy. Lymph nodes involvement is common in differentiated thyroid cancer, and cervical lymph node micrometastases are observed in up to 85% of patients with papillary thyroid cancer during surgery. While the therapeutic central lymph node dissection has been accepted, the debate on the prophylactic in differentiated thyroid carcinoma (DTC) continues.

125I Seed Brachytherapy for Refractory Loco-Regional Recurrence of Non-Anaplastic Thyroid Cancer

Purpose

The purpose of this research was to evaluate the feasibility and efficacy of ¹²⁵I seed brachytherapy as salvage treatment for recurrence from non-anaplastic thyroid cancer refractory to other modalities.

Methods

Between June 2006 and September 2019, fifteen patients with recurrent non-anaplastic thyroid cancer were treated with ¹²⁵I seed brachytherapy. ¹²⁵I seeds were implanted into the tumor under the guidance of CT and/or ultrasound images with the median prescription dose of 120 Gy (range, 100-140 Gy). The median seed number was 80 (range 10-214). Clinical efficacy was evaluated with Response Evaluation Criteria in Solid Tumors.

Findings

Fifteen patients were selected, eleven of whom had papillary carcinoma, two suffered from follicular carcinoma, and two were diagnosed with medullary carcinoma. These patients had twenty-four nodes in total. After they received salvage surgery and/or radioactive iodine (RAI) therapy, local recurrence was detected in all of them. No less than one node was observed in everyone’s cervical or supraclavicular areas, and four patients had lung metastatic. The median follow-up period lasted 48 months (range, 5-93 months). All patients did not develop locoregional recurrence after experiencing ¹²⁵I seed brachytherapy. Only three of them formed new metastases in nontarget regional nodes after brachytherapy, and additional brachytherapy can solve all regional failure problems. No significant adverse events were observed in any patient.

Implications

For the chosen patients, 125I seed brachytherapy is feasible for treating refractory local recurrence from non-anaplastic thyroid cancer. Further studies are required to determine the role of 125I seed brachytherapy in the treatment of thyroid cancer.

Is Performance of Routine Central Compartment Neck Dissection in cN0 Papillary Thyroid Cancers Really Useful? 10-Year Prospective Observational Study

Central compartment nodes of neck are the first echelon nodes in papillary thyroid cancers (PTC). This study analyses the adverse parameters associated with central compartment nodal metastasis in cN0 PTC and also the usefulness of performing central compartment neck dissection routinely. A total of 236 patients with cNo PTC who underwent prophylactic central compartment neck dissection, from January 2008 to June 2017 in the Department of Oncology, Madurai Medical College, were included in study. Analysis of various adverse factors associated with central compartment nodal metastasis was made. Patients (46.18%) had metastatic nodes in the central compartment. Incidence of nodal metastasis increased with tumour size, capsular invasion, extrathyroidal extension, tracheal invasion and pulmonary metastasis. More than 50% patients did not have any of the statistically significant known adverse risk factors except for age and sex. Routine central compartment neck dissection has therapeutic value in PTC even in absence of known adverse factors and can be recommended in cases of clinically negative nodes. A meticulous dissection in experienced hands carries less complication rates as with thyroidectomy alone. In a resource limited country like ours, where the cost of re-surgery and radioiodine scans are high, a meticulous initial surgery incorporating central compartment neck dissection would really mean a difference.

3D-Printed Template-Guided 125I Seed Brachytherapy: A Salvage Approach for Locoregional Refractory Recurrence of Papillary Thyroid Cancer

BACKGROUND

Papillary thyroid carcinoma (PTC) is typically treated with surgical resection, even in recurrent cases. However, some cases of recurrent PTC are refractory to the conventionally used locoregional radiotherapy and resection methods. ¹²⁵I seed permanent brachytherapy has emerged as a promising alternative for such PTCs, but no effective brachytherapy protocol has been reported for tumors with a huge volume, liquefaction, necrosis, and skin invasion.

CASE PRESENTATION

A 47-year-old man presented with recurrence 8 years after 2 thyroidectomy procedures for PTC and recurrent PTC. The tumor measured 6 × 7 × 8 cm³ and exhibited liquefaction, necrosis, and skin invasion. The patient was treated at our hospital from December 2017 to November 2018. He received one round of ¹²⁵I seed temporary brachytherapy and 4 rounds of ¹²⁵I seed permanent implantation. The activity of the seeds was 0.3-3.0 mCi, and the total dose delivered to the tumor was 145 Gy. The recurrent tumor was successfully removed by ¹²⁵I seed brachytherapy guided with a 3D-printed template and ultrasound and CT scanning. The refractory tumor healed uneventfully after ¹²⁵I seed brachytherapy without recurrence over the 25-month follow-up.

CONCLUSIONS

To the best of our knowledge, this is the first reported case of a large thyroid carcinoma that was effectively treated by 3D-printed template-guided ¹²⁵I seed brachytherapy.

Change in worry over time among Hispanic women with thyroid cancer

PURPOSE

The purpose of this study is to assess change in worry over time in Hispanic women with thyroid cancer.

METHODS

Worry about recurrence, quality of life, family at risk, death, and harm from treatments was assessed in 273 Hispanic women with thyroid cancer diagnosed in 2014-2015. Subjects were recruited from Surveillance, Epidemiology, and End Results (SEER) Los Angeles. Participants were surveyed at two points in time (time 1: 2017-2018 and time 2: 2019). Multivariable logistic regression was used to determine correlates with high worry (somewhat, quite a bit, very much) versus low worry (not at all, a little) at time 2.

RESULTS

For the five worry items, 20.1-39.6% had high worry at both time 1 and time 2. An additional 7.6-13.4% had low worry at time 1 that became high worry at time 2. In multivariable logistic regression controlling for age, recurrence status, education level, and number of complications or side effects symptoms, younger age (20-39) as compared to older (40-79) was associated with high worry about thyroid cancer recurrence (OR 2.16, 95% CI 1.12-4.17). History of recurrent or persistent disease was associated with high worry about harms from treatment (OR 2.94, 95% CI 1.29-6.67). Greater number of complications or side effects of symptoms was associated with more worry across all five items.

CONCLUSIONS

Some Hispanic women with thyroid cancer have persistently high worry, with young adult Hispanic women vulnerable to worry about recurrence.

IMPLICATIONS FOR CANCER SURVIVORS

Hispanic women with thyroid cancer may benefit from targeted psychosocial support during survivorship, with interventions informed by patient and cancer characteristics.

Treatment Efficacy of Radiofrequency Ablation for Recurrent Tumor at the Central Compartment After Hemithyroidectomy

OBJECTIVE. The aim of this study was to evaluate the efficacy of ultrasound (US)-guided radiofrequency ablation (RFA) for recurrent tumor in the central compartment after hemithyroidectomy. MATERIALS AND METHODS. The medical records of patients who underwent RFA for recurrent tumor after hemithyroidectomy between January 2008 and December 2018 were reviewed. Eight patients who underwent RFA for 10 recurrent tumors after hemithyroidectomy were included in our study population. Patients underwent follow-up US 1, 6, and 12 months after treatment and annually thereafter. The tumor volume reduction rate (VRR) was calculated as follows: VRR = ([initial volume - final volume] × 100) / initial volume. All patients were advised to undergo contrast-enhanced CT after tumor ablation. Complete tumor disappearance was defined as no visible treated tumor on follow-up US or CT. RESULTS. Mean tumor VRR was 97.8% ± 7.0% (SD) (range, 77.8-100%). Complete tumor ablation was achieved for all 10 recurrent tumors. Complete disappearance was confirmed in nine recurrent tumors, and one recurrent tumor showed a VRR of 77.8% on US but there was no enhancement on CT. All eight patients achieved no evidence of disease during mean follow-up of 33.0 months. RFA was tolerated by all patients; there were no major complications or procedure-related deaths. One patient experienced transient voice change during RFA. CONCLUSION. RFA can be considered to be an effective and safe alternative treatment method for recurrent tumor in the central compartment after hemithyroidectomy.

The Impact of Coexistent Hashimoto's Thyroiditis on Central Compartment Lymph Node Metastasis in Papillary Thyroid Carcinoma

BACKGROUND

Hashimoto's thyroiditis (HT) is the most prevalent inflammatory disorder of the thyroid gland. Current studies have reported the coexistence rate between HT and papillary thyroid carcinoma (PTC) is quite high. The objective of this study was to evaluate the impact of HT on the predictive factors of central compartment lymph node metastasis (CLNM) in PTC.

METHODS

A retrospective investigation was performed on PTC patients. They were subclassified into HT and non-HT groups. The results of preoperative neck ultrasound (US) examinations were reviewed. The clinical characteristics and the predictive value for CLNM were explored and compared between the two groups.

RESULTS

A total of 756 patients were included in this study. There were more female patients (86.1%) in the PTC coexistent with the HT group than non-HT group. The patients with HT group had higher preoperative serum level of TSH. There was statistically significant difference between the HT patients and non-HT patients in nodular vascularization. Univariate and multivariate analyses showed that male, age ≤45 years old, tumor diameter >1 cm, and presence of suspicious central compartment lymph node on US, irregular nodular shape, multifocal carcinoma were independent predictive factors of CLNM in PTC patients. It was showed that male, age ≤45 years old, tumor diameter >1 cm, multifocality, and presence of suspicious central lymph node on US were risk factors for CLNM in non-HT patients. Only tumor diameter >1 cm and presence of suspicious central lymph node on US were independently correlated with CLNM in HT patients. The sensitivity of the multivariate model was 63.5%, and specificity was 88.9% for prediction CLNM in HT patients. For non-HT patients, the AUC was 80.6%, the sensitivity of the multivariate model was 64.5%, and specificity was 85.2.

CONCLUSION

PTC combined with HT is more common in women, and TSH level in HT group is higher than that in patients with PTC alone. Regardless of that HT is not a related risk factor of CLNM in PTC, our result suggested that different predictive systems should be used for HT and non-HT patients respectively to have a more accurate evaluation of CLNM in clinic.

Clinical Relevance and Management of Recurrent Laryngeal Nerve Inlet Zone Lymph Nodes Metastasis in Papillary Thyroid Cancer

BACKGROUND

Recurrent nodal disease often occurs in recurrent laryngeal nerve inlet zone (RLNIZ), leading to difficult surgical management.

METHODS

Medical records of 947 patients with PTC and 33 patients with recurrent PTC were retrospectively reviewed. Totally 169 sides of RLNIZ dissection in 152 patients (17 cases were bilateral and 135 cases were unilateral) with primary surgery and 4 patients with structural recurrent disease were included for the analysis.

RESULTS

The rate of lymph node metastasis in RLNIZ was 31.3% (47/150). The incidence of transient hypoparathyroidism was 5.9% and no RLN injury and permanent hypoparathyroidism occurred. RLNIZ lymph nodes metastasis (LNM) was significantly associated with age <45 years, larger tumor size, number of CNLNM, and lateral node metastasis. CNLNM and lateral node metastasis were independent risk factors for RLNIZ LNM. Recurrent nodal disease in RLNIZ was identified in four of 33 patients and permanent recurrent laryngeal nerve (RLN) injury was observed in one of four patients.

CONCLUSION

Lymph nodes in RLNIZ are usually involved in patients with heavy tumor burden and can be removed safely at initial surgery. Once central or lateral LNM was confirmed preoperatively or intraoperatively, RLNIZ lymph node dissection should be carefully performed to reduce the rate of structural recurrence in the central compartment.

Unilateral papillary thyroid carcinoma treated with contralateral central lymph node dissection: A nomogram to aid in decision-making

The central lymph nodes of the neck are the most common sites of papillary thyroid carcinoma (PTC) but cannot be easily diagnosed preoperatively. Prophylactic central lymph node dissection (CLND), especially contralateral CLND, is not recommended in various guidelines due to its high risk. The aim of our study was to establish an objective point score based on preoperative and intraoperative data to guide the selection of patients for contralateral CLND.We retrospectively evaluated 1085 consecutive patients with PTC treated by thyroidectomy for inclusion in this study (the training cohort). Variables of contralateral central lymph node macro-metastasis (CLNMM) were investigated using univariate and multivariate analyses; subsequently, nomograms were developed and then validated in an independent cohort of patients (n = 326, the validation cohort).Univariate and multivariate analyses indicated that preoperative fine needle aspiration-proven ipsilateral lateral lymph node metastasis (LNM) (odds ratio [OR] 4.888, 95% confidence interval [CI] 1.587-41.280, P < .001) and cases with frozen-section pretracheal LNM (OR 19.015, 95% CI 2.949-186.040, P < .001) or Delphian LNM (OR 4.494, 95% CI 1.503-54.128, P < .001) were the 3 risk factors for contralateral CLNMM. A receiver operating characteristic curve indicated a cutoff value of 1 for the frozen-section pretracheal LNM number or the Delphian LNM number as a predictor of contralateral central lymph node metastasis (CLNM). The nomogram was then generated according to the 3 risk factors and well validated in the external cohorts, and the intraoperative frozen-section results were highly consistent with the postoperative pathological results.The proposed nomogram based on the 3 factors showed a good prediction of contralateral CLNMM in PTC.

Prophylactic lymph node dissection in clinically N0 differentiated thyroid carcinoma: example of personalized treatment

Considering the 'differentiated thyroid carcinoma (DTC) epidemic', the indolent nature of DTC imposes a treatment paradigm shift toward elimination of recurrence. Lymph node metastases in cervical compartments, encountered in 20-90% of DTC, are the main culprit of recurrent disease, affecting 5-30% of patients. Personalized risk-stratified cervical prophylactic lymph node dissection (PLND) at initial thyroidectomy in DTC with no clinical, sonographic or intraoperative evidence of lymph node metastases (clinically N0) has been advocated, though not unanimously. The present review dissects the controversy over PLND. Weighing the benefit yielded from PLND up against the PLND-related morbidity is so far hampered by the inconsistent profit yielded by PLND and the challenging patient selection. Advances in tailoring PLND are anticipated to empower optimal patient care.

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.

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.

Recognizing Persistent Disease in Well-Differentiated Thyroid Cancer and Association with Lymph Node Yield and Ratio

OBJECTIVE

To establish the association between lymph node yield and ratio in neck dissection for well-differentiated thyroid cancer and risk for persistent postoperative disease.

STUDY DESIGN

Retrospective cohort study of patients undergoing lymphadenectomy for thyroid carcinoma.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

Included patients underwent central and/or lateral neck dissection for papillary thyroid carcinoma at our institution between 1994 and 2015. They were divided into a persistent disease group with biochemical and structural disease (49 patients) and a disease-free group with no disease after a minimum 2 years of follow-up (175 patients). Demographic characteristics, adjuvant therapy, tumor, and lymph node features were compared.

RESULTS

There were no significant differences in demographic characteristics between the groups. The mean nodal yield of patients with central and lateral neck persistence was significantly lower than that of patients remaining disease free (4.8 vs. 11.9: odds ratio [OR] 0.69; 95% CI, 0.59 to 0.8; P < .001; 14.8 vs. 31.0: OR, 0.89; 95% CI, 0.84-0.94; P < .001, respectively). Nodal ratio was higher in patients with persistence in the central and lateral neck (74.2% vs 29.4%: OR, 1.06; 95% CI, 1.04-1.08; P < .001; 54.2% vs 19.8%: OR, 1.08; 95% CI, 1.04-1.12; P < .001, respectively).

CONCLUSIONS

Lower lymph node yield and higher node ratio from cervical lymph node dissections are associated with persistent disease and have potential applications in surgical adequacy.

Recurrent Papillary Thyroid Carcinoma to the Cervical Lymph Nodes: Outcomes of Compartment-Oriented Lymph Node Resection

INTRODUCTION

Recurrence of papillary thyroid carcinoma after initial treatment is challenging. Surgical reintervention is recommended, but cure after surgery in uncertain and surgical morbidity may be high. This study evaluates the effect of compartment-oriented lymph node dissection (LND) on clinical and biochemical cure rate as well as the related complications.

PATIENTS AND METHODS

All patients who underwent LND for recurrent papillary thyroid carcinoma between 2000 and 2015 were included. Demography, the extent of the initial surgery, usage of ¹³¹I, the pattern of recurrence, diagnosis, details of the surgical reintervention, histological findings, surgical morbidity, and clinical and biochemical outcomes were analyzed.

RESULTS

There were 11 (12.7%) males and 75 (87.2%) females with a mean age of 42.8 ± 14.6 years. Seventy-seven patients had undergone total thyroidectomy and in 67 (77.9%) some type of LN resection. In 76 (88.3%), ¹³¹I was administered after the initial surgery. We localized suspicious lymph nodes by US in all patients, and metastases were documented before surgery by FNA in 63. Seven (8.13%) patients underwent central LND, 63 (73.2%) lateral LND and 16 (18.6%) both, central and lateral LND. Major complications occurred in 6 patients (6.9%). Sixty-two (72.0%) patients received ¹³¹I after surgery. A second surgical re-exploration was performed in 30 (34.8%) patients, and 7 patients required 3 or more additional LND. In a mean follow-up of 59.4 ± 39 months, 51 (59.3%) patients are clinically, radiologically and biochemically free of disease.

CONCLUSIONS

In this series, compartment-oriented lymph node resection of recurrent papillary thyroid carcinoma leads to a final clinical and biochemical disease-free status of 59.3% with 6.9% of major complications.

Central compartment revision surgery for persistent or recurrent thyroid carcinoma: analysis of survival and complication rate

PURPOSE

Locoregional recurrence of thyroid carcinoma is relatively common and reported rate are between 5 and 20%. Cervical nodes are usually involved, especially at the central compartment. The management of recurrent thyroid carcinoma at central compartment still remains challenging because of higher incidence of complication rate. The aim of the study is to evaluate the survival and complications rate after revision surgery.

METHODS

Retrospective cohort study on a group of patients that underwent revision surgery for persistent or recurrent thyroid carcinoma from January 1, 2003 to December 31, 2017. Survival outcomes were calculated using Kaplan-Meier method. Significant variables on univariate analysis were subjected to a Cox proportional hazards regression multivariate model.

RESULTS

Fifty-two patients involved, 22 male (40%) and 30 female (60%). Mean age was 54 years old (range 24-85). Mean follow-up was 79 months, median follow-up was 85 months, with a range between 8 and 153 months. The 5-year overall survival was 90.8% while at 10 years it was 69.8%. The 5-year disease-specific survival was 93.5%, while at 10 years it dropped to 77.9%. The rate of recurrent laryngeal nerve paralysis and persistent hypocalcemia in our series were 1.3% and 5.9%, respectively. No evidence of thoracic duct, esophageal or laryngeal and tracheal injury was found in this case series. Regarding prognostic factors, univariate and multivariate analysis highlighted as statistically significant: the aggressive histological variants, the presence extranodal extension or soft-tissue metastasis.

CONCLUSION

The surgical option remains the gold standard in locoregional recurrences of thyroid carcinoma and should be performed by experienced surgeons to reduce postoperative complications.

Surgical outcomes of thyroid cancer patients in a tertiary cancer center in India

Background

Surgery is the mainstay in the management of thyroid cancer. Surgical outcomes need to be tempered against the excellent prognosis of the disease.

Aims

This study aims to study the surgical outcomes including the 30-day morbidity and 5-year survival of thyroid cancer patients.

Settings and Design

Retrospective analysis of a prospectively maintained surgical database in a tertiary cancer center in India.

Materials and Methods

We analyzed 221 surgically treated patients in the year 2012.

Statistical Analysis

Used IBM SPSS 24.0 (Armonk, NY) with p < 0.05.

Results

The median age was 40 years with predominantly papillary thyroid carcinoma (55%). Localized disease in 47% of cases, locoregional disease in 42.5% and distant metastasis in 10.2% of cases at presentation was noted. Treatment naïve patients were 71% and revision surgeries were done in 29% patients. Extended thyroidectomy constituted 11% of the surgeries. Temporary hypocalcemia was seen in 30.8% of patients, 5% requiring intravenous calcium supplementation. Vocal cord palsy as per nerve at risk and chyle leak were seen in 4.5% and 3.1%, respectively. Aggressive histology, extended thyroidectomy, and inadvertent parathyroidectomy were significant factors associated with complications. Five year estimated overall survival with median follow-up of 50 months was 98%, and event-free survival was 84.8%. Advanced age, distant metastasis at presentation and aggressive histology connoted poor outcomes.

Conclusion

Thyroid cancer, irrespective of the extent of disease, has good prognosis. Aggressive histology, the extent of thyroid surgery, distant metastasis and age are important factors, which should be factored in the algorithm of thyroid cancer management.

Routine thyroglobulin, neck ultrasound and physical examination in the routine follow up of patients with differentiated thyroid cancer-Where is the evidence?

PURPOSE

Patients with differentiated thyroid cancer (DTC) typically have a favourable prognosis and recurrence as late as 45 years after diagnosis has been reported. International clinical guidelines for monitoring recommend routine thyroglobulin, ultrasound and physical examination for the detection of recurrence. The aim of this review was to systematically review whether routine monitoring using thyroglobulin (Tg), neck ultrasound and physical examination for recurrence in differentiated thyroid cancer patients is effective in improving patient survival and/or quality of life.

METHODS

Primary studies were retrieved via a comprehensive search of three electronic bibliographic databases (PubMed, Web of Science Core Collection and Cochrane Library) without time restriction. Eligible studies must have reported on disease-free patients with DTC subject to long-term routine surveillance. The primary and secondary outcomes of interest were overall survival (or other survival parameters) and quality of life, respectively.

RESULTS

Literature searches yielded 5529 citations, which were screened by two reviewers. 241 full texts were retrieved. No randomised controlled trials or two-arm cohort studies on the effectiveness of any of the three specified interventions were identified. However, three 'single-arm' studies reporting long-term follow-up outcomes in patients undergoing regular surveillance were identified and appraised.

CONCLUSIONS

This review highlights a lack of empirical evidence to support current use of routine surveillance in DTC. Although early detection is possible, routine surveillance may lead to unnecessary intervention.

Risk of recurrence in a homogeneously managed pT3-differentiated thyroid carcinoma population

BACKGROUND

International guidelines for the management of differentiated thyroid cancers are based on the 7th TNM classification: pT3 tumors are defined as differentiated thyroid cancers (DTCs) measuring more than 4 cm in their greatest dimension that are limited to the thyroid or any tumor with minimal extrathyroidal extension (ETE; sternothyroid muscle or perithyroid soft tissues). Differences in clinicohistological features and prognosis among patients with pT3 tumors remain controversial, and studies regarding pT3 subgroups are lacking.

OBJECTIVE

To analyze the prognosis of four subgroups of pT3 DTCs (papillary, PTC; or follicular, FTC).

DESIGN AND SETTING

The data of patients who underwent surgery for pT3 DTC between 1978 and 2015 in a surgical department specialized in endocrine surgery were reviewed. Patients were classified into four groups as follows: the pT3a (≤ 10 mm with ETE), pT3b (10-40 mm with ETE), pT3c (> 40 mm without ETE), and pT3d groups (> 40 mm with ETE). Recurrence-free survival (RFS) was analyzed using the Kaplan-Meier method.

RESULTS

One thousand eighty-eight patients with pT3 DTC were included, of whom 311 (29%) had pT3a; 548 (50%), pT3b; 165 (15%), pT3c; and 64 (6%), pT3d. For the 916 patients with lymph node (LN) dissection, metastatic LNs were more frequent in the pT3b and pT3d groups (61 and 61%, respectively) than in the other groups (44% pT3a and 10% pT3c; p < 0.001). During the median follow-up period of 9 years (range, 2-38 years), recurrence occurred in 169 patients with T3 tumors (16%), including 18 with pT3a (6%), 100 with pT3b (18%), 20 with pT3c (12%), and 31 with pT3d (48%). In a multivariate analysis, LN metastases (< 0.0001), extranodal extension (p = 0.03), FTC (vs. PTC) (p = 0.006), pT3b (p = 0.016), and pT3d (p = 0.047) were associated with an increased risk of recurrence. The 5-year RFS rates were 94.5, 82.2, 91.1, and 50.3% for the pT3a, pT3b, pT3c, and pT3d groups, respectively (p < 0.01).

CONCLUSION

Except for microcarcinoma, the risk of LN involvement is high and similar for the DTC patients with minimal ETE, regardless of the size of the tumor. The association of a tumor size of > 4 cm and ETE are associated with a poor prognosis and should justify the classification of these cases as a high-risk group. Other pT3 patients with no LN metastases could be individualized as a low-risk group.

Optimization of the risk-benefit ratio of differentiated thyroid cancer treatment

The vast majority of differentiated thyroid cancers (DTC) are characterized by an innocuous nature, excellent patient survival, and limited treatment requirement. However, a significant proportion of affected patients is prone to receiving overtreatment, due to undertreatment concerns associated with the difficulty to differentiate them from a small minority affected by aggressive DTC. Identification of prognostic factors and development of staging systems has helped to reduce the proportion of overtreatment in DTC. However, the absolute number of overtreated patients continues to increase, as a result of an on-going incidence surge in early DTC associated with the increased application and sensitivity of modern diagnostic tools. In the present paper, we describe how DTC treatment can be optimized by thoughtful evidence-based balancing of oncologic safety against treatment associated morbidity.

Clinicopathologic Predictive Factors of Cervical Lymph Node Metastasis in Differentiated Thyroid Cancer

BACKGROUND

Cervical lymph node metastasis (LNM) has been proven to be a predictor for locoregional recurrence in differentiated thyroid carcinoma (DTC). Clinicopathological features could be effective predictive factors for central and lateral LNM of DTC, and provide references to surgeons for cervical neck dissection.

METHODS

Retrospective analysis of clinicopathological data was performed on 420 patients who underwent initial surgery from 2010 to 2015.

RESULTS

The incidence of central and lateral LNM was calculated. Of 420 patients, 247 (58.8%) exhibited central LNM, and 185 (44.1%) exhibited lateral LNM. There were 29 (6.9%) cases confirmed to have skip metastasis. Univariate and multivariate analysis revealed that tumour location, tumour size, multifocality, capsular invasion, affected lobes, and age were independent predictors of central LNM. Tumour location, capsular invasion, affected lobes, and tumour size were independent predictors of lateral LNM.

CONCLUSIONS

Our findings suggest that tumour location, affected lobes, capsular invasion, age, tumour size and multifocality may be taken as predictive factors for cervical LNM of DTC. Meticulous perioperative evaluation of cervical LNM and prophylactic cervical lymph node dissection that aims to remove the occult lymph nodes may be an option for DTC with risk factors.

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.

Controversies in the Management of Low-Risk Differentiated Thyroid Cancer

Controversy exists over optimal management of low-risk differentiated thyroid cancer. This controversy occurs in all aspects of management, including surgery, use of radioactive iodine for remnant ablation, thyroid hormone supplementation, and long-term surveillance. Limited and conflicting data, treatment paradigm shifts, and differences in physician perceptions contribute to the controversy. This lack of physician consensus results in wide variation in patient care, with some patients at risk for over- or undertreatment. To reduce patient harm and unnecessary worry, there is a need to design and implement studies to address current knowledge gaps.

The Role of Central Neck Lymph Node Dissection in the Management of Papillary Thyroid Cancer

Papillary thyroid cancer (PTC) is the most common thyroid malignancy, and cervical nodal metastases are frequent at presentation. The most common site for nodal metastases from PTC is the central compartment of the ipsilateral neck in the paratracheal and pretracheal regions. The decision to resect these lymph nodes at the time of thyroidectomy often depends on if nodes with suspected malignancy can be identified preoperatively. If nodal spread to the central neck nodes is known, then the consensus is to remove all nodes in this area. However, there remains significant controversy regarding the utility of removing central neck lymph nodes for prophylactic reasons. Herein, we review the potential utility of central neck lymph node dissection as well as the risks of performing this procedure. As well, we review the potential of molecular testing to stratify patients who would most benefit from this procedure. We advocate a selective approach in which patients undergo clinical neck examination coupled with ultrasound to detect any concerning lymph nodes that warrant additional evaluation with either fine needle aspiration or excisional biopsy in the operating room. In lieu of clinical lymphadenopathy, we suggest the use of patient and disease characteristics as identified by multiple groups, such as the American Thyroid Association and European Society of Endocrine Surgeons, which include extremes of ages, large primary tumor size, and male gender, when deciding to perform central neck lymph node dissection. Patients should be educated on the potential long-terms risks versus the lack of known long-term benefits.

Predictive factors of right paraesophageal lymph node metastasis in papillary thyroid carcinoma: Single center experience and meta-analysis

BACKGROUND

We performed this retrospective study to identify predictors of right paraesophageal lymph node metastasis, and reviewed previous studies related to this topic.

METHODS

Between June 2005 and March 2015, 1107 patients were diagnosed with papillary thyroid carcinoma and underwent surgery at Pusan National University Hospital.

RESULTS

Right paraesophageal lymph node metastasis was observed in 171 (15.4%) patients. Multivariate analyses showed that the risk of right paraesophageal metastasis was significantly associated with tumor size, location, a higher number of metastatic central lymph nodes, and lateral lymph node metastasis. In a meta-analysis of the eligible studies, tumor size, number of metastatic central lymph nodes, and lateral lymph node metastasis showed significant relationships with the risk of right paraesophageal metastasis.

CONCLUSIONS

In patients with risk factors such as those identified in our study, the possibility of right paraesophageal metastasis should be kept in mind, and careful inspection and dissection are required.

Risk Stratification of Neck Lesions Detected Sonographically During the Follow-Up of Differentiated Thyroid Cancer

CONTEXT

The European Thyroid Association (ETA) has classified posttreatment cervical ultrasound findings in thyroid cancer patients based on their association with disease persistence/recurrence.

OBJECTIVE

The objective of the study was to assess this classification's ability to predict the growth and persistence of such lesions during active posttreatment surveillance of patients with differentiated thyroid cancer (DTC).

DESIGN

This was a retrospective, observational study.

SETTING

The study was conducted at a thyroid cancer center in a large Italian teaching hospital.

PATIENTS

Center referrals (2005-2014) were reviewed and patients selected with pathologically-confirmed DTC; total thyroidectomy, with or without neck dissection and/or radioiodine remnant ablation; abnormal findings on two or more consecutive posttreatment neck sonograms; and subsequent follow-up consisting of active surveillance. Baseline ultrasound abnormalities (thyroid bed masses, lymph nodes) were classified according to the ETA system. Patients were divided into group S (those with one or more lesions classified as suspicious) and group I (indeterminate lesions only). We recorded baseline and follow-up clinical data through June 30, 2015.

MAIN OUTCOMES

The main outcomes were patients with growth (>3 mm, largest diameter) of one or more lesions during follow-up and patients with one or more persistent lesions at the final visit.

RESULTS

The cohort included 58 of the 637 DTC cases screened (9%). A total of 113 lesions were followed up (18 thyroid bed masses, 95 lymph nodes). During surveillance (median 3.7 y), group I had significantly lower rates than group S of lesion growth (8% vs 36%, P = .01) and persistence (64% vs 97%, P = .014). The median time to scan normalization was 2.9 years.

CONCLUSIONS

The ETA's evidence-based classification of sonographically detected neck abnormalities can help identify papillary thyroid cancer patients eligible for more relaxed follow-up.

Safety of Completion Thyroidectomy for Initially Misdiagnosed Thyroid Carcinoma

INTRODUCTION

Completion thyroidectomy is defined as the surgical removal of the remnant thyroid tissue following procedures of less than total or near-total thyroidectomy. Whether thyroid reoperations are associated with an increased complication risk is controversial.

OBJECTIVE

A retrospective analysis was done of patients undergoing completion thyroidectomy for cancer of the thyroid who had undergone surgery elsewhere for solitary thyroid nodule. The incidence of surgical complications in these patients after reoperation was investigated in this study.

MATERIAL AND METHODS

The study included a total of 53 patients who had undergone thyroid lobectomy for a solitary nodule as initial surgery elsewhere and were referred to our institute for completion thyroidectomy when the histopathology revealed malignancy.

RESULTS

There were 53 patients, 43 females and 10 males. Their mean age was 34.7±12.12 years (range 19-65 years). After initial surgery, the histopathology revealed papillary carcinoma in 46 patients (86.8%), follicular carcinoma in 7 (13.2%). Fourteen out of 53 patients had recurrent laryngeal nerve palsy after initial surgery (26.4%). None of the patients had clinical hypocalcemia after the first surgery. One or more parathyroid glands were identified and preserved in 52 patients (98.1%) in the process of completion thyroidectomy. No patient had additional recurrent nerve injury at the second surgery. The mean serum calcium value preoperatively was 8.96±0.39 mg/dL, and six months after surgery serum calcium was 8.74±0.56 mg/dL. Mean follow-up was 18 months. Transient hypoparathyroidism occurred in 24.5% patients. Five patients were lost to follow-up. Permanent and symptomatic hyperparathyroidism occurred in eight patients (16.67%).

CONCLUSIONS

Completion thyroidectomy is a safe and appropriate option in the management of well-differentiated thyroid cancer. It removes disease on the ipsilateral and contralateral side of the thyroid and carries a low risk of recurrent laryngeal nerve damage, but a higher risk of permanent hypoparathyroidism.

The weepy nerve-different sensitivity of left and right recurrent laryngeal nerves under tensile stress in a porcine model

PURPOSE

Recurrent laryngeal nerve palsy in thyroid surgery is still a threatening complication. Our aim was to analyze the impact of prolonged tensile stress on the recurrent laryngeal nerve (RLN) in an animal model using continuous intraoperative neuromonitoring (C-IONM).

METHODS

Constant tensile stress was applied to left and right RLNs in 20 pigs (40 RLN). In a pilot study, five animals were subjected to a tensile force of 0.34 ± 0.07 N for 10 min and changes in amplitude were documented using C-IONM. In the main study, a force of 1.2 N was applied until the signal amplitude was reduced by 85 %, in 15 pigs. Nerve conductivity was analyzed by threshold current measurements.

RESULTS

Good correlation was found between stress and amplitude decrease in the pilot study as well as between signal decrease and duration of trauma in the main study. Great variations were found inter- and intra-individually. These variations were most prominent at 85 % signal reduction (median 36 min, range 0.3-171 min). There was no side specificity (left 0.3-171 min, right 0.3-168 min, respectively, p = 0.19). However, in each individual animal, there was a sensitive (0.3-98.9 min) and less sensitive nerve (26.8-171 min). These differences became highly significant at 85 % of signal reduction (p = 0.008), where the vulnerability is 1.4 to 146.4 times higher on one side (mean 4.3).

CONCLUSIONS

Our study demonstrates the presence of a sensitive RLN that was 4.3 times more vulnerable than the contralateral nerve (range 1.4-146.4 times, p = 0.008). Thus, the right and the left nerves cannot be assumed to be of equal sensitivity to trauma. In our data, the more sensitive nerve does not occur predominantly on one side and was named the "weepy nerve."

Prophylactic neck dissection for low-risk differentiated thyroid cancers: Risk-benefit analysis

BACKGROUND

The benefit of neck dissection is the subject of debate in differentiated thyroid cancer (DTC). We analyze the risk-benefit of neck dissection for low-risk DTC without detectable lymph nodes.

METHODS

We conducted a retrospective study from 1983 to 2003; which included 295 patients without detectable lymph nodes who were treated by thyroidectomy with (C+) or without (C-) neck dissection. All patients had iodine131 therapy. We compared the frequency of remission, disease progression, and permanent complications between groups.

RESULTS

Two hundred twelve patients comprised the C+ group, and 83 patients the C- group. Respectively for C+ versus C-, remission rates were 92% versus 89.2% (p = .40), and progressive disease observed was 3.3% versus 7.2% (p = .10). Permanent hypoparathyroidism occurred in 15.1% in C+ versus 3.6% in C- (p = .006).

CONCLUSION

The risk-benefit analysis of neck dissection in patients with low-risk DTC shows no benefit in terms of complete remission or occurrence of progression. However, risk of complications seems to be higher in patients with neck dissection. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1091-1096, 2016.

Contemporary Management of Recurrent Nodal Disease in Differentiated Thyroid Carcinoma

Differentiated thyroid carcinoma (DTC) comprises over 90% of thyroid tumors and includes papillary and follicular carcinomas. Patients with DTC have an excellent prognosis, with a 10-year survival rate of over 90%. However, the risk of recurrent tumor ranges between 5% and 30% within 10 years of the initial diagnosis. Cervical lymph node disease accounts for the majority of recurrences and in most cases is detected during follow-up by ultrasound or elevated levels of serum thyroglobulin. Recurrent disease is accompanied by increased morbidity. The mainstay of treatment of nodal recurrence is surgical management. We provide an overview of the literature addressing surgical management of recurrent or persistent lymph node disease in patients with DTC.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Risk factors and indication for dissection of right paraesophageal lymph node metastasis in papillary thyroid carcinoma

BACKGROUND

Right paraesophageal lymph nodes (RPELNs) are located behind right recurrent laryngeal nerve which often ignored in central compartment lymph nodes (LNs) dissection of papillary thyroid carcinoma (PTC) patients. The aim of this study was to identify the risk factors for RPELN metastasis and indications for RPELN dissection.

METHODS

Medical record of 246 consecutive PTC patients (194 female, 52 male), who underwent total thyroidectomy (244 patients) or right lobectomy (2 patients) with central compartment LN dissection (13 ipsilateral and 233 bilateral), were reviewed. The RPELNs were kept separately during the operation. The clinical pathology data was collected and analyzed.

RESULTS

RPELN metastasis was confirmed in 33 patients (13.4%) and were discovered in 18.5% (31/168) of right lesion, 34.4% (31/90) of right central group LN (rCLN) metastasis, 33.3% (18/54) of lateral compartment LN (LLN) metastasis, 25.7% (9/35) of local recurrent patients respectively. The ultrasound suspected metastatic LNs, tumor diameter, tumor number, tumor location, and numbers of metastatic Delphian LNs, central group LNs (CLNs), rCLNs, and LLNs between patients with and without RPELN metastasis showed significant differences in univariate analysis (P < 0.05). In multivariate analysis, number of metastatic rCLNs (1-2: OR 13.6, 95% CI, 2.7-67.5; ≧3: OR39.4, 95% CI, 7.7-200.9), right side tumor (OR 6.4, 95% CI, 1.1-35.6), and three or more metastatic LLNs (OR 3.5, 95% CI, 1.2-10.2) were independent risk factors for RPELN metastasis.

CONCLUSIONS

PTC patients with right lobe lesions, especially with potential rCLN metastasis, are at considerable risk of RPELN metastasis. RPELN dissection should be considered in these patients.

Recurrence of papillary thyroid carcinoma with lateral cervical node metastases: Predictive factors and operative management

BACKGROUND

Lateral neck lymph node (LN) metastases (N1b) have been identified as independent risk factors of recurrence in patients with papillary thyroid carcinoma (PTC).

OBJECTIVE

This study aimed to determine the predictive factors of recurrence in N1b PTC patients and to clarify the postoperative event patterns.

METHODS

All patients who underwent operation for N1b PTC between 1978 and 2012 were reviewed. The median follow-up period was 6.5 years.

RESULTS

In total, 344 N1b patients were included. Twenty-four patients (7%) were lost to long-term follow-up. Among the remaining 320 patients, the mean (± SD) follow-up time was 8.9 ± 8.8 years (median, 6.5; range, 2-36.4). Eighty-two patients (26%) presented with lymph node recurrence (LR). Multivariate analyses showed that LN metastases with extracapsular extension and the LN ratio (ratio between the number of N1 and number of resected LN) in the lateral compartment were independent predictors of recurrent disease. The median time to reoperation was 19 months (range, 3-173), with 79% of reoperations occurring within 2 years after the initial thyroidectomy. Reoperations for LR (75 patients) were performed in 76% of the patients with a focused minimal access approach or selective LN dissection. After curative reoperative surgery for recurrence, complications occurred in 6 patients (8%), including a 1% permanent complication rate.

CONCLUSION

Extranodal extension of LN metastases and the LN ratio in the lateral compartment are prognostic factors for recurrence. In most cases, reoperation for LR can be performed with a focused minimal access approach, with a low morbidity rate.

Local recurrence of papillary thyroid cancer

Management of advanced papillary thyroid cancer (PTC >10 mm) is changing its focus. Mortality was the main outcome measure for patients treated before the 90s. In the past two decades, however, most patients diagnosed with PTC belong to the very low risk of death group. On the other hand, local recurrence of PTC remains a clinical problem, with rates up to 25% depending on the presence of nodal metastasis, tumor diameter, and the skill of the surgeon to completely remove the primary tumor and the associated lymph node metastasis at first-time thyroidectomy. After optimized surgery (total thyroidectomy plus central neck dissection), radioiodine ablation has very little influence on lymph node recurrence that now presents mostly as lateral neck node metastasis that was overlooked or incompletely resected at the time of initial surgery.