A comparative analysis of endoscopic thyroidectomy versus conventional thyroidectomy in clinically lymph node negative thyroid cancer

Emerging therapeutic options for follicular-derived thyroid cancer in the era of immunotherapy

Although most follicular-derived thyroid cancers are well differentiated and have an overall excellent prognosis following treatment with surgery and radioiodine, management of advanced thyroid cancers, including iodine refractory disease and poorly differentiated/undifferentiated subtypes, is more challenging. Over the past decade, better understanding of the genetic drivers and immune milieu of advanced thyroid cancers has led to significant progress in the management of these patients. Numerous targeted kinase inhibitors are now approved by the U.S Food and Drug administration (FDA) for the treatment of advanced, radioiodine refractory differentiated thyroid cancers (DTC) as well as anaplastic thyroid cancer (ATC). Immunotherapy has also been thoroughly studied and has shown promise in selected cases. In this review, we summarize the progress in the understanding of the genetic landscape and the cellular and molecular basis of radioiodine refractory-DTC and ATC, as well as discuss the current treatment options and future therapeutic avenues.

Surgical outcomes of endoscopic thyroidectomy approaches for thyroid cancer: a systematic review and network meta-analysis

Objectives

This network meta-analysis assesses the outcomes of seven endoscopic approaches, offering valuable insights for researchers and practitioners in choosing the best method for thyroid cancer patients.

Methods

A systematic literature search was conducted in the PubMed, Embase and Web of Science databases up to March 2023. The analysis included seven endoscopic approaches, with a focus on their respective outcomes through network meta-analysis.

Results

This meta-analysis included 44 studies involving 8,672 patients. The axillo-bilateral breast approach (ABBA) and unilateral axillo-breast approach (UABA) showed advantages in terms of reduced operative time compared to other approaches (MD = 19.66 minutes, 95% CI = -31.66 to 70.98; MD = 30.32 minutes, 95% CI = -1.45 to 62.09, respectively). The UABA and anterior chest approach (ACA) exhibited superiority in controlling intraoperative bleeding (MD = -3.37 mL, 95% CI = -22.58 to 15.85; MD = -13.77 mL, 95% CI = -28.85 1.31, respectively). UABA and ACA also showed advantages in reducing hospital stays (MD = -0.39 days, 95% CI = -1.48 to 0.71; MD = -0.26 days, 95% CI = -1.33 to 0.81, respectively). The transoral approach (OA) yielded results comparable to those of conventional open thyroidectomy (COT) and outperformed other endoscopic surgeries with regards to lymph node retrieval and metastatic lymph node assessment. For the stimulated serum thyroglobulin (TG) levels, no significant difference was observed between bilateral axillo-breast approach (BABA) and OA compared to COT. However, chest-breast approach (CBA) showed significantly lower levels than COT (MD=-0.40 ng/ml, 95% CI =-0.72 to -0.09). Patients in the gasless unilateral transaxillary approach (GUA) group experienced a significant improvement in cosmetic satisfaction (MD=-2.08, 95% CI =-3.35 to -0.82). Importantly, no significant difference was observed in the incidence of surgical complications between endoscopic thyroidectomy and COT.

Conclusion

Endoscopic thyroid surgery is a safe and effective choice for thyroid cancer patients. Different approaches have their advantages, allowing personalized selection based on the patient's needs. ABBA and UABA have shorter operative times, while UABA and ACA excel at controlling bleeding and shortening hospital stays. OA shows promise for lymph node assessment. These findings contribute to the growing evidence supporting endoscopic methods, expanding treatment options for thyroid cancer patients.

Efficacy and Safety of Minimally Invasive Thyroid Surgery: A Network Meta-Analysis

OBJECTIVES

Minimally invasive and remote surgical approaches for thyroid tumors have been developed primarily for cosmetic benefit. However, conventional meta-analysis could not provide comparative data between new techniques. This network meta-analysis would be able to provide data for clinicians and patients to compare cosmetic satisfaction and morbidity by comparing surgical methods.

DATA SOURCES

The PubMed, EMBASE, MEDLINE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar.

REVIEW METHODS

The nine interventions included minimally invasive video-assisted thyroidectomy (MIVA), endoscopic and robotic bilateral axillo-breast-approach thyroidectomy (EBAB and RBAB, respectively), endoscopic and robotic retro-auricular thyroidectomy (EPA and RPA, respectively), endoscopic or robotic transaxillary thyroidectomy (EAx and RAx, respectively), endoscopic and robotic transoral approaches (EO and RO, respectively), and a conventional thyroidectomy. We recorded the operative outcomes and perioperative complications; pairwise and network meta-analyses were performed.

RESULTS

EO, RBAB, and RO were associated with good patient cosmetic satisfaction. EAx, EBAB, EO, RAx, and RBAB were associated with significantly more postoperative drainage than the other methods. Postoperatively, more flap problems and wound infections were found in the RO than control group, and more transient vocal cord palsy was found in the EAx and EBAB groups. MIVA ranked first in terms of operative time, postoperative drainage amount, postoperative pain, and hospitalization, but cosmetic satisfaction was low. EAx, RAx, and MIVA ranked higher than the other approaches in terms of operative bleeding.

CONCLUSION

It was confirmed that minimally invasive thyroidectomy achieves high cosmetic satisfaction and is not inferior to conventional thyroidectomy in terms of surgical results or perioperative complications. Laryngoscope, 133:2470-2479, 2023.

Surgical completeness and safety of minimally invasive thyroidectomy in patients with thyroid cancer: A network meta-analysis

BACKGROUND

To assess the surgical outcomes of various minimally invasive and remote-access surgical approaches for thyroid cancer patients.

METHODS

We collected studies from January 2020 to July 2022 in 6 databases. Pairwise and network meta-analyses were performed for outcomes and complications of 9 minimally invasive interventions (minimally invasive video-assisted, endoscopic or robotic bilateral axillo-breast approach, endoscopic or robotic postauricular, endoscopic or robot transaxillary approach, transoral endoscopic thyroidectomy vestibular approach or robotic thyroidectomy) and conventional thyroidectomy (control).

RESULTS

Multiplicity and bilaterality of cancer, lymph node metastasis, and coincidence of thyroiditis showed no significant difference between minimally invasive interventions and control. However, larger tumor size (robotic bilateral axillo-breast approach standardized mean difference -1.3989, 95% confidence interval [-2.1717 to -0.6262]), higher body mass index (robot transaxillary approach standardized mean difference -0.5350, 95% confidence interval [-0.9557 to -0.1144], robotic bilateral axillo-breast approach standardized mean difference -0.2301, 95% confidence interval [-0.4389 to -0.0214]), and frequent extrathyroidal extension (robotic bilateral axillo-breast approach standardized mean difference 0.7435, 95% confidence interval [0.5602-0.9869]) were observed in control. In surgical outcomes and adverse effects, there was no significant difference in hospitalization or retrieved lymph node number between minimally invasive interventions and control. However, longer operative time was observed in the robotic bilateral axillo-breast approach(standardized mean difference 6.5393, 95% confidence interval [5.0476-8.0309]) and transoral robotic thyroidectomy (standardized mean difference 5.4946, 95% confidence interval [2.9984-7.9907]) groups than in control. In surgical completion, the rate of low postoperative serum thyroglobulin, postoperative thyroglobulin level, and postoperative radioactive iodine ablation dose showed no significant difference between minimally invasive interventions and control.

CONCLUSION

Minimally invasive thyroidectomy did not show inferior results compared to conventional thyroidectomy despite the longer operative time. Surgeons need to prudently consider all aspects of patients to determine the proper surgical approach for thyroid cancer.

Multidimensional Analyses of the Learning Curve of Endoscopic Thyroidectomy

BACKGROUND

Endoscopic thyroidectomy has comparable surgical outcomes and superior cosmetic satisfaction to open thyroidectomy. However, steep learning curve is a concern. This study evaluated the learning curve of endoscopic thyroidectomy using various parameters and statistical methods.

METHODS

A total of 90 consecutive patients who underwent endoscopic thyroidectomy using bilateral axillo-breast approach (BABA) between March 2016 and April 2020 were enrolled. Operative time, postoperative drainage amount, and blood loss were assessed by cumulative sum (CUSUM) analysis and moving average to evaluate the learning curve.

RESULTS

Using the CUSUM analysis, the peak point of both operative time and drainage amount occurred at the 30th case. No clear single peak was identified in the CUSUM plot for blood loss. The moving average also showed significant reduction in operative time and drainage amount after, approximately, the first 30 cases. The blood loss decreased after the 25th case. We therefore divided the patients into 2 phases: phase 1 (1-30 cases) and phase 2 (31-90 cases). The operative time, drainage amount, and blood loss decreased significantly in the phase 2 compared with phase 1. Lower pain score in first postoperative day and shorter hospital stay were also observed in the phase 2. Although the reduction in transient hypoparathyroidism did not reach statistical significance, no permanent hypoparathyroidism was noted in the phase 2.

CONCLUSIONS

The learning curve for endoscopic thyroidectomy is approximately 30 cases. Aside from the operative time, drainage amount may also serve as a surrogate for the learning curve evaluation.

Trends in Oncology: an Updated Review of Minimally Invasive Surgery vs. Traditional Open Surgery

Objective: To review the recent trends in methodology for the most frequent oncological surgeries. More specifically, this paper will compare the minimally invasive methods to the conventional open method. It aims to find out whether minimally invasive surgeries are feasible treatments for certain types of cancers.

Methods: A review of retrospective studies searched in PubMed, Cochrane Library etc. was used to identify the studies published on this topic within a period of 6 years. Oncologic outcomes, postoperative complications/outcomes, and intraoperative outcomes were the main variables in the comparison to the surgical methods under review.

Conclusion: Despite the recent controversy with minimally invasive surgery being contraindicated for cervical cancer, it is still an acceptable method for other types of common cancers. However, there are limitations to the approach, and the surgeon should make a prudent selection between minimally invasive and open surgery depending on the type of tumor and patient characteristics. Further studies, especially with randomized control trials, must be conducted.

The Immune Landscape of Thyroid Cancer in the Context of Immune Checkpoint Inhibition

Immune cells play critical roles in tumor prevention as well as initiation and progression. However, immune-resistant cancer cells can evade the immune system and proceed to form tumors. The normal microenvironment (immune cells, fibroblasts, blood and lymphatic vessels, and interstitial extracellular matrix (ECM)) maintains tissue homeostasis and prevents tumor initiation. Inflammatory mediators, reactive oxygen species, cytokines, and chemokines from an altered microenvironment promote tumor growth. During the last decade, thyroid cancer, the most frequent cancer of the endocrine system, has emerged as the fifth most incident cancer in the United States (USA), and its incidence is steadily growing. Inflammation has long been associated with thyroid cancer, raising critical questions about the role of immune cells in its pathogenesis. A plethora of immune cells and their mediators are present in the thyroid cancer ecosystem. Monoclonal antibodies (mAbs) targeting immune checkpoints, such as mAbs anti-cytotoxic T lymphocyte antigen 4 (anti-CTLA-4) and anti-programmed cell death protein-1/programmed cell death ligand-1 (anti-PD-1/PD-L1), have revolutionized the treatment of many malignancies, but they induce thyroid dysfunction in up to 10% of patients, presumably by enhancing autoimmunity. Combination strategies involving immune checkpoint inhibitors (ICIs) with tyrosine kinase (TK) or serine/threonine protein kinase B-raf (BRAF) inhibitors are showing considerable promise in the treatment of advanced thyroid cancer. This review illustrates how different immune cells contribute to thyroid cancer development and the rationale for the antitumor effects of ICIs in combination with BRAF/TK inhibitors.

Total endoscopic thyroidectomy versus conventional open thyroidectomy in thyroid cancer: a systematic review and meta-analysis

Background

Despite the considerable experience gained thus far using endoscopic technologies, the role of total endoscopic thyroidectomy (ET) for papillary thyroid cancer (PTC) remains controversial. We conducted a systematic review and meta-analysis to investigate the safety and effectiveness of total ET compared with conventional open thyroidectomy (OT) in PTC.

Methods

A systematic search was conducted using the PubMed, Embase and Cochrane Library electronic databases up to March 2018. The quality of included studies was evaluated using the Newcastle–Ottawa Scale. Review Manager software version 5.3 was used for the meta-analysis.

Results

Twelve studies including 2,672 patients were ultimately included in the systematic review and meta-analysis. ET was associated with longer operative time (P<0.00001), drainage time (P<0.00001) and hospital stay (P=0.03), higher transient recurrent laryngeal nerve (RLN) palsy rate (P=0.004) and a greater amount of drainage fluid (P<0.0001) compared with OT. Furthermore, no significant differences were detected between ET and OT in terms of retrieved lymph nodes (P=0.17), blood loss (P=0.22), transient hypocalcemia (P=0.84), permanent hypocalcemia (P=0.58), permanent RLN palsy (P=0.14), hematoma or bleeding (P=0.15) and seroma (P=0.54). In addition, the rates of tumor recurrence were comparable (P=0.18), whereas the proportions of stimulated thyroglobulin levels <1 ng/mL measured after completion of thyroidectomy and radioactive iodine therapy were less (P=0.02) in the ET than in the OT group.

Conclusion

ET is not superior to OT in terms of operation and drainage time, amount of drainage fluid, hospital stay or transient RLN palsy, but is comparable to OT in terms of retrieved lymph nodes and permanent complications. Despite the similar tumor recurrence rates between the two approaches, the level of surgical completeness in ET may not be as good as that for OT.

Comparison of endoscopic thyroidectomy via a modified axillo-breast approach with the conventional breast approach for treatment of unilateral papillary thyroid microcarcinoma

Endoscopic thyroidectomy (ET) via an axillo-breast (ABA), axillary or breast approach (BA) is effective for treatment of unilateral papillary thyroid microcarcinoma (PTMC). However, several disadvantages still exist, including inconvenience for using endoscopic instruments and poor cosmetic results. Here, we introduced a modified ABA (MABA) to overcome these disadvantages and evaluated its therapeutic outcomes by comparison with conventional BA.Fifty-five patients undergoing ET via MABA (n = 22) or BA (n = 33) for PTMC were retrospectively enrolled between June 2012 and June 2015. Surgical outcomes, including the operation time, blood loss, amount of drainage, number of dissected lymph nodes, complications, cosmetic satisfaction and prognosis (recurrence and survival), were analyzed.The operation time (87.1 ± 9.3 min vs 93.2 ± 8.3 min; P = .014) and drainage tube removal time (4.4 ± 1.0 days vs 5.1 ± 1.1 days; P = .018) were shorter in the MABA group than those in the BA group. There was less postoperative drainage (54.3 ± 35.7 mL vs 137.6 ± 87.0 mL; P < .01) in the MABA group compared with the BA group. No significant differences in the blood loss (15.9 ± 7.5 mL vs 19.2 ± 11.7 mL, P = .243) and the number of dissected lymph nodes (1.8 ± 1.5 vs 2.3 ± 2.1, P = .309) were observed between the 2 groups. Subcutaneous ecchymosis occurred more frequently in the BA group than that in the MABA group (33.3% vs 9.1%; P = .038). Patients treated by MABA were more satisfied with their cosmetic results than those undergoing BA (100% vs 81.8%; P = .034). At the last follow-up time, all patients were alive although 1 patient in the BA group developed cervical lymph node recurrence ipsilateral to the original tumor at 4 years after surgery. Multivariate logistic regression analysis showed MABA surgery was a protective factor for postoperative complications (OR = 0.209, 95% confidence interval [CI] = 0.054-0.817, P = .024).ET via the MABA strategy may be a good choice for unilateral PTMC because of shorter operation time, fewer complications, greater cosmetic satisfaction, and excellent prognosis.

Complete endoscopic radical resection of thyroid cancer via an oral vestibule approach

The aim of the present study was to explore the feasibility, safety and effectiveness of complete endoscopic radical resection of thyroid cancer via an oral vestibule approach. A total of 60 patients with unilateral thyroid papillary carcinoma were divided into two groups. Half of them underwent complete endoscopic surgeries via an oral vestibule approach at the Department of Head and Neck Surgery of Fujian Cancer Hospital between November 2014 and December 2016. The other 30 patients underwent traditional open surgeries. All the patients underwent unilateral lobectomy and central neck dissection. Tumor diameter, surgery duration, intraoperative inflation pressure and end-tidal CO₂ flow rate, intraoperative peak value of the partial pressure of end-tidal CO₂, postoperative extubation time, the number of lymph nodes in the specimens of central neck dissection and postoperative complications were noted. From this data, tumor diameter (T stage of tumor), surgery duration, postoperative extubation time, the number of lymph nodes in the specimens of central neck dissection and postoperative complications were compared between the two groups. In the endoscopic group, 1 patient had a tracheal injury, and 1 patient had a submental skin perforation. Furthermore, 17 patients experienced transient numbness of the lower lip, 5 patients experienced an abnormal increase in the partial pressure of end-tidal CO₂, and 2 patients experienced postoperative headache. No recurrent laryngeal nerve injury, postoperative bleeding, or infection was determined. There were no significant differences in all items of the indexes, compared with those patients who underwent open radical surgery. The lymph nodes from region VI may be well exposed and completely removed through this novel procedure with no visible scars, which not only ensured the surgery criterion was met, but also met the cosmetic requirements of the patients. The present study conducted procedures safely by surgeons highly skilled in performing laparoscopic surgery.

Three-dimensional versus two-dimensional endoscopic-assisted thyroidectomy via the anterior chest approach: a preliminary report

OBJECTIVE

The objective of the study was to evaluate the safety and effectiveness of three-dimensional (3D) endoscopy for thyroidectomy and compare it to two-dimensional (2D) endoscopy. The major limitations of conventional endoscopy include its lack of depth perception and tactile feedback. The 3D endoscopy technique, which involves 3D imaging, is widely used. However, few reports have described the use of 3D endoscopic systems in thyroid surgery.

METHOD

In this single-institutional study, 103 consecutive patients who underwent endoscopic thyroidectomy between July 2013 and April 2014 were enrolled. Of these, 32 patients chose 3D endoscopy, and 71 patients chose 2D endoscopy and were used as a control group. All patients were stratified by type of operation.

RESULT

All 103 patients underwent a successful endoscopic-assisted thyroidectomy with no conversion to open surgery. There were no differences in operation time, intraoperative bleeding, postoperative drainage, the number of lymph nodes (LNs) dissected, major complications, and hospital stays. During a median follow-up of 28.0 months, no patients experienced a recurrence of thyroid cancer.

CONCLUSION

Our preliminary report demonstrates that 3D endoscopy achieved the same level of safety and effectiveness as 2D endoscopy in endoscopic-assisted thyroidectomies. Additionally, 3D endoscopy provided good depth perception and allowed the surgeon to easily recognize critical anatomical landmarks. Further large-scale studies, preferably prospective randomized control trials, are required to confirm this finding.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) for Graves' disease: a comparison of surgical results with open thyroidectomy

BACKGROUND

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) provides excellent cosmetic results from its potential for scar-free operation. The procedure has been applied successfully for Graves' disease by the authors of this work and compared with the standard open cervical approach to evaluate its safety and outcomes.

METHODS

From January 2014 to November 2016, a total of 97 patients with Graves' disease were reviewed retrospectively. Open thyroidectomy (OT) and TOETVA were performed in 49 patients and 46 patients, respectively. For TOETVA, a three-port technique through the oral vestibule was utilized. The thyroidectomy was done endoscopically using conventional laparoscopic instruments and an ultrasonic device. Patient demographics and surgical variables, including operative time, blood loss, and complications, were investigated and compared.

RESULTS

TOETVA was performed successfully in all 45 patients, although conversion to open surgery was deemed necessary in one patient. All patient characteristics for both groups were similar. Operative time was shorter for the OT group compared to the TOETVA group, which totaled 101.97±24.618 and 134.11±31.48 minutes, respectively (P<<0.5). Blood loss was comparable for both groups. The visual analog scale (VAS) pain score for the TOETVA group was significantly lower than for the OT group on day 1 (2.08±1.53 vs. 4.57±1.35), day 2 (0.84±1.12 vs. 2.57±1.08) and day 3 (0.33±0.71 vs. 1.08±1.01) (P<<0.05). Transient recurrent laryngeal nerve (RLN) palsy was found in four and two cases of TOETVA and OT group, respectively. Transient hypocalcemia was found in ten and seven cases of TOETVA and OT group, respectively. No other complications were observed.

CONCLUSIONS

TOETVA is a feasible and safe treatment for Graves' disease in comparison to the standard open cervical approach. It is considered a viable alternative for patients who have been indicated for surgery with excellent cosmetic results.

Transoral Endoscopic Thyroidectomy Vestibular Approach: A Series of the First 60 Human Cases

BACKGROUND

Natural orifice transluminal endoscopic surgery has been adopted for thyroid surgery because of its potential for scar-free operation. However, the previous technique still has some limitations. Thus, we present our initial experience in transoral endoscopic thyroidectomy vestibular approach (TOETVA).

METHODS

From April 2014 to January 2015, we used a three-port technique through the oral vestibule, one 10-mm port for laparoscope and two additional 5-mm ports for instruments. The CO2 insufflation pressure was set at 6 mm Hg. An anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch. The thyroidectomy was done endoscopically using conventional laparoscopic instruments and an ultrasonic device.

RESULTS

A series of 60 procedures were accomplished successfully. 42 patients had single-thyroid nodules, and a lobectomy was performed. 22 patients had multinodular goiters and two patients had Graves' disease, with total thyroidectomy or Hartley-Dunhill procedures performed. Two had papillary thyroid carcinoma, and total thyroidectomy with central node dissection was performed. The median operative time was 115.5 min (range 75-300 min). The median blood loss was 30 mL (range 8-130 mL). Two patients experienced a transient hoarseness, which was resolved within 2 months. One patient experienced a late postoperative hematoma, which was treated conservatively. No mental nerve injury or infections were found. The patients were discharged in an average of 3.6 days (range 2-7 days) postoperatively.

CONCLUSION

TOETVA is safe and feasible, resulting in no visible scarring. This technique may provide a method for ideal cosmetic results.

Transoral Endoscopic Thyroidectomy Vestibular Approach: A Series of the First 60 Human Cases

BACKGROUND

Natural orifice transluminal endoscopic surgery has been adopted for thyroid surgery because of its potential for scar-free operation. However, the previous technique still has some limitations. Thus, we present our initial experience in transoral endoscopic thyroidectomy vestibular approach (TOETVA).

METHODS

From April 2014 to January 2015, we used a three-port technique through the oral vestibule, one 10-mm port for laparoscope and two additional 5-mm ports for instruments. The CO2 insufflation pressure was set at 6 mm Hg. An anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch. The thyroidectomy was done endoscopically using conventional laparoscopic instruments and an ultrasonic device.

RESULTS

A series of 60 procedures were accomplished successfully. 42 patients had single-thyroid nodules, and a lobectomy was performed. 22 patients had multinodular goiters and two patients had Graves' disease, with total thyroidectomy or Hartley-Dunhill procedures performed. Two had papillary thyroid carcinoma, and total thyroidectomy with central node dissection was performed. The median operative time was 115.5 min (range 75-300 min). The median blood loss was 30 mL (range 8-130 mL). Two patients experienced a transient hoarseness, which was resolved within 2 months. One patient experienced a late postoperative hematoma, which was treated conservatively. No mental nerve injury or infections were found. The patients were discharged in an average of 3.6 days (range 2-7 days) postoperatively.

CONCLUSION

TOETVA is safe and feasible, resulting in no visible scarring. This technique may provide a method for ideal cosmetic results.