Molecular Alterations and Comprehensive Clinical Management of Oncocytic Thyroid Carcinoma: A Review and Multidisciplinary 2023 Update

Importance

Oncocytic (Hürthle cell) thyroid carcinoma is a follicular cell-derived neoplasm that accounts for approximately 5% of all thyroid cancers. Until recently, it was categorized as a follicular thyroid carcinoma, and its management was standardized with that of other differentiated thyroid carcinomas. In 2022, given an improved understanding of the unique molecular profile and clinical behavior of oncocytic thyroid carcinoma, the World Health Organization reclassified oncocytic thyroid carcinoma as distinct from follicular thyroid carcinoma. The International Thyroid Oncology Group and the American Head and Neck Society then collaborated to review the existing evidence on oncocytic thyroid carcinoma, from diagnosis through clinical management and follow-up surveillance.

Observations

Given that oncocytic thyroid carcinoma was previously classified as a subtype of follicular thyroid carcinoma, it was clinically studied in that context. However, due to its low prevalence and previous classification schema, there are few studies that have specifically evaluated oncocytic thyroid carcinoma. Recent data indicate that oncocytic thyroid carcinoma is a distinct class of malignant thyroid tumor with a group of distinct genetic alterations and clinicopathologic features. Oncocytic thyroid carcinoma displays higher rates of somatic gene variants and genomic chromosomal loss of heterozygosity than do other thyroid cancers, and it harbors unique mitochondrial DNA variations. Clinically, oncocytic thyroid carcinoma is more likely to have locoregional (lymph node) metastases than is follicular thyroid carcinoma-with which it was formerly classified-and it develops distant metastases more frequently than papillary thyroid carcinoma. In addition, oncocytic thyroid carcinoma rarely absorbs radioiodine.

Conclusions and Relevance

The findings of this review suggest that the distinct clinical presentation of oncocytic thyroid carcinoma, including its metastatic behavior and its reduced avidity to radioiodine therapy, warrants a tailored disease management approach. The reclassification of oncocytic thyroid carcinoma by the World Health Organization is an important milestone toward developing a specific and comprehensive clinical management for oncocytic thyroid carcinoma that considers its distinct characteristics.

Quality of life following surgery for head and neck cancer: Evidence from ACRIN 6685

BACKGROUND

This study examined the trajectory of health-related quality of life (HRQoL) for patients with clinical stage N0 HNSCC enrolled in ACRIN 6685 who underwent elective neck dissection(s).

METHODS

HRQoL of 230 patients in the ACRIN 6685 trial was measured prospectively up to 2 years following surgery using the University of Washington Quality of Life instrument.

RESULTS

General Health Within the Last 7 Days did not differ significantly from baseline at any follow-up. General Health Relative to Before Cancer fell significantly by 5.8 points following surgery (p = 0.048), and then returned to 3.0 points above baseline at 1 year (p = 0.65). For Overall Quality of Life, HRQoL fell significantly by 4.3 points following surgery (p = 0.031) and then returned to levels not significantly different from baseline.

CONCLUSIONS

Patients with stage N0 HNSCC experience significant declines in HRQoL immediately following surgery, including neck dissection, which recovers to near or better than baseline within 1-2 years.

Autofluorescence of Parathyroid Glands: A Review of Methods of Parathyroid Gland Identification and Parathyroid Vascular Assessment

Postoperative hypoparathyroidism may cause significant patient morbidity and even mortality. Emerging technologies centered on autofluorescent properties of parathyroid glands when exposed to near-infrared light hold promise to improve surgical parathyroid gland identification and preservation. Two systems (probe-based and camera-based) are commercially available currently; however, neither system alone provides indication of vascular viability or postoperative parathyroid gland function. The administration of indocyanine green, when combined with near-infrared fluorescence imaging, enables subjective assessment of parathyroid gland perfusion. Additional technologies to assess parathyroid gland perfusion are being developed. The impact of these nascent technologies on relevant clinical outcomes is an area of active investigation.

Secondary Hyperparathyroidism

Secondary hyperparathyroidism (SHPT) does not initiate as a primary dysfunction of parathyroid glands resulting from an intrinsic defect or disease but is the physiologic response of parathyroids to metabolic changes elsewhere in the body occurring over time. SHPT is a manifestation of a chronic condition that classically occurs from chronic kidney disease. In fact, given the relatively recent transition of populations from outside (agrarian) to indoor (industrial, information technology, and so forth) employment and a consequent reduction in sun exposure, combined with diets of highly processed food, vitamin D and calcium deficiencies are now the leading causes of SHPT.

Subjective Voice Outcomes in Surgeon Versus Technician-Monitored Recurrent Laryngeal Nerves in Thyroidectomy

OBJECTIVES

To compare subjective voice outcomes and postoperative laryngoscopic examination findings of patients with subjective voice complaints between surgeon-monitored and certified technician-monitored thyroidectomies.

METHODS

Patients who underwent hemithyroidectomy, total thyroidectomy, and completion thyroidectomy using a nerve monitoring system between November 2015 and June 2018 were included in the study. Retrospective chart review was carried out to assess how often patients reported voice changes and to record postoperative flexible laryngoscopic findings of patients when that examination was performed. Data were analyzed using the χ2 test to identify significant differences in outcomes for the 2 groups.

RESULTS

A total of 293 procedures was performed among 3 surgeons. Surgeons monitored the nerves in 147 cases and a certified technician monitored the nerves in 146 cases. Subjective voice changes were identified in 11 (7.48%) cases in the surgeon-monitored group and in 20 (13.70%) cases in the technician-monitored group (P = .084). Among the patients who expressed subjective voice changes, 7 patients were identified with vocal cord hypomobility or immobility in the surgeon-monitored group and 13 patients had an abnormal examination in the technician-monitored group (P = .234).

CONCLUSIONS

Subjective voice changes or proven vocal cord mobility problems were not different between surgeon-monitored patients and technician-monitored patients in thyroidectomies.

Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid Surgery: A Review From the American Head and Neck Society Endocrine Surgery Section

Importance

Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery.

Observation

This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)-both label free and in combination with indocyanine green-based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery.

Conclusions and Relevance

Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.

Analysis of Unmet Information Needs Among Patients With Thyroid Cancer

Importance

Counseling prior to thyroid cancer (TC) treatment is an essential component of informed consent. An informed patient affects treatment-related expectations and patient engagement, factors that contribute significantly to patient-reported quality-of-life outcomes.

Objective

To describe experiences with pretreatment counseling among survivors of TC and to test factors associated with self-reported treatment meeting expectations.

Design, Setting, and Participants

A cross-sectional survey was administered between October 18, 2019, and February 8, 2020, to members of ThyCa: Thyroid Cancer Survivors' Association Inc, and to individuals accessing the public-facing ThyCa website. Survey respondents were asked 55 questions, including 4 free-text questions and 2 multiple-choice questions about pretreatment counseling.

Main Outcomes and Measures

Respondents self-reported (1) their unmet information needs, (2) rates of treatment meeting expectations, and (3) rates of treatment understanding. A mixed-methods analysis was performed, including qualitative content analysis of free-text responses and multivariable logistic regression of factors associated with self-reported levels of treatment meeting expectations.

Results

Of the 1412 survey respondents, 1249 were women (88.4%). The median age at diagnosis was 48 years (range, 18-85 years), and the median age at the time of survey completion was 60 years (range, 18-87 years). A total of 1259 respondents (89.2%) provided free-text responses to the question, "What would you tell someone newly diagnosed with your same condition?" Of these individuals, 526 (37.2%) reported inadequate pretreatment plan understanding and 578 (40.9%) reported that their treatment experience did not meet their expectations. Treatment met expectations for only 95 respondents (18.1%) reporting an inadequate pretreatment plan understanding. Of the 526 survivors of TC reporting a lack of understanding, 473 (90.0%) provided additional textual comments, most commonly in the categories of postoperative treatment, surveillance, and treatment effects. On multivariable logistic regression, self-reported failure to have an understanding of TC treatment was independently associated with failure of treatment to meet expectations (odds ratio, 5.1 [95% CI, 3.7-6.9]). Patients reporting a full understanding of their treatment plan were 5-fold more likely to indicate that their initial treatment experience was on par with expectations, independent of reported postoperative complications, age, sex, and other potential confounders.

Conclusions and Relevance

In this survey study, a substantial proportion of survivors of TC reported inadequate pretreatment understanding. This gap in understanding was associated with high levels of self-reported failure of treatment to meet expectations, which in turn is associated in other studies with poorer patient-reported quality-of-life outcomes. These outcomes may be improved by addressing gaps in patient understanding so expectations more closely match TC diagnosis and treatment pathways.

Impact of Neck PET/CT Positivity on Survival Outcomes-Visual and Quantitative Assessment: Results From ACRIN 6685

INTRODUCTION

FDG PET/CT was prospectively studied in 287 cN0 head and neck cancer patients in ACRIN 6685, and additional analysis of neck FDG uptake upon recurrence-free survival (RFS) and overall survival (OS) was performed.

PATIENTS AND METHODS

Two hundred eight had analyzable data. Survival analysis was performed to compare RFS and OS based on neck FDG visual assessment (VA) and SUV max . For SUV max , the optimal thresholds were calculated using conditional inference trees on a randomly selected 70% training data set and validated using the remaining 30% of data. Kaplan-Meier curves with log-rank tests were generated for the patient groups based on VA and optimal SUV max thresholds, and the hazards ratios (HRs) and 95% confidence intervals (CIs) were also calculated. Hypothesis testing was set at a significance level of 0.05.

RESULTS

A total of 73.9% of bilateral cN0 and 50.0% of unilateral cN0 were alive at the end of the study with the remaining being dead or lost to follow-up. Overall survival median follow-up time was 24.0 months (interquartile range, 15.8-25.3; range, 0-37.0). A total of 63.3% of bilateral cN0 and 42.5% of unilateral cN0 patients remained disease free during the study. Recurrence-free survival median follow-up time was 23.9 months (interquartile range, 12.4-25.2; range, 0-35.6). Visual assessment of necks by our panel of radiologists was significantly associated with RFS (HR [95% CI], 2.30 [1.10-4.79]; P = 0.02), but not with OS (HR [95% CI], 1.64 [0.86-3.14]; P = 0.13). The optimal SUV max thresholds were 2.5 for RFS and 5.0 for OS. For SUV max assessment, applying the optimal thresholds to the 30% test data yielded HRs (95% CIs) of 2.09 (0.61-7.14; P = 0.23) for RFS and 3.42 (1.03-11.41; P = 0.03) for OS. The SUV max threshold of 5.0 was significantly associated with RFS (HR [95% CI], 5.92 [1.79-19.57]; P < 0.001).

CONCLUSIONS

Neck FDG uptake by VA is significant for RFS. An SUV max threshold of 5.0 is significantly associated with OS and RFS.

Remote smart pill cap monitoring of post-surgical pain management in thyroid and parathyroid surgery

BACKGROUND

With recent efforts to decrease opioid use following surgery, this study aims to answer: what pain regimen do patients follow at home? Is it controlling pain?

METHODS

This is a prospective, pilot study of thyroid and parathyroid surgery patients. Patients were prescribed acetaminophen, ibuprofen, and tramadol dispensed in smart pill (Pillsy) bottles that record "events" corresponding to medication use. Patients received messages querying their current pain level. Patients were compared to historical controls.

RESULTS

26 patients were in the Pillsy group and 30 in the control group. In the Pillsy group, pain scores averaged 3.67 out of 10 in the first 24 h after surgery and decreased each day. Patients took an average of 6.45 doses of acetaminophen, 6.64 doses of ibuprofen, and 1.82 doses of tramadol in the first week.

CONCLUSIONS

Pain scores are highest in the first 24 h after surgery and decrease thereafter. This acceptable level of pain can be achieved with non-opioid medications.

18F-FDG PET/CT Staging of Head and Neck Cancer: Interobserver Agreement and Accuracy-Results from Multicenter ACRIN 6685 Clinical Trial

To our knowledge, no prior multicenter clinical trial has reported interobserver agreement of 18F-FDG PET/CT scans for staging of clinical N0 neck in head and neck cancer. Methods: A total of 287 participants were recruited. For visual analysis, positive nodal uptake of 18F-FDG was defined as uptake visually greater than activity seen in the blood pool. Results: The negative predictive value of the 18F-FDG PET/CT for N0 clinical neck was 86% or above for visual assessment (95% CI, 86%-88%) for the 2 central readers and above 90% (95% CI, 90%-95%) for SUVmax for central reads and site reads dichotomized at the optimal cutoff value of 1.8 and the prespecified cutoff value of 3.5, respectively. The κ coefficients between the 2 expert readers and between central reads and site reads varied between 0.53 and 0.78. Conclusion: The NPV of the 18F-FDG PET/CT for N0 clinical neck was 86% or above for visual assessment and above 90% for SUVmax cut points of 1.8 and 3.5 with moderate to substantial agreements.

Evaluating the Rising Incidence of Thyroid Cancer and Thyroid Nodule Detection Modes: A Multinational, Multi-institutional Analysis

Importance

There is epidemiologic evidence that the increasing incidence of thyroid cancer is associated with subclinical disease detection. Evidence for a true increase in thyroid cancer incidence has also been identified. However, a true increase in disease would likely be heralded by an increased incidence of thyroid-referable symptoms in patients presenting with disease.

Objectives

To evaluate whether modes of detection (MODs) used to identify thyroid nodules for surgical removal have changed compared with historic data and to determine if MODs vary by geographic location.

Design, Setting, and Participants

This was a retrospective analysis of pathology and medical records of 1328 patients who underwent thyroid-directed surgery in 16 centers in 4 countries: 4 centers in Canada, 1 in Denmark, 1 in South Africa, and 12 in the US. The participants were the first 100 patients (or the largest number available) at each center who had thyroid surgery in 2019. The MOD of the thyroid finding that required surgery was classified using an updated version of a previously validated tool as endocrine condition, symptomatic thyroid, surveillance, or without thyroid-referable symptoms (asymptomatic). If asymptomatic, the MOD was further classified as clinician screening examination, patient-requested screening, radiologic serendipity, or diagnostic cascade.

Main Outcomes and Measures

The MOD of thyroid nodules that were surgically removed, by geographic variation; and the proportion and size of thyroid cancers discovered in patients without thyroid-referable symptoms compared with symptomatic detection. Data analyses were performed from April 2021 to February 2022.

Results

Of the 1328 patients (mean [SD] age, 52 [15] years; 993 [75%] women; race/ethnicity data were not collected) who underwent thyroid surgery that met inclusion criteria, 34% (448) of the surgeries were for patients with thyroid-related symptoms, 41% (542) for thyroid findings discovered without thyroid-referable symptoms, 14% (184) for endocrine conditions, and 12% (154) for nodules with original MOD unknown (under surveillance). Cancer was detected in 613 (46%) patients; of these, 30% (183 patients) were symptomatic and 51% (310 patients) had no thyroid-referable symptoms. The mean (SD) size of the cancers identified in the symptomatic group was 3.2 (2.1) cm (median [range] cm, 2.6 [0.2-10.5]; 95% CI, 2.91-3.52) and in the asymptomatic group, 2.1 (1.4) cm (median [range] cm, 1.7 [0.05-8.8]; 95% CI, 1.92-2.23). The MOD patterns were significantly different among all participating countries.

Conclusions and Relevance

This retrospective analysis found that most thyroid cancers were discovered in patients who had no thyroid-referable symptoms; on average, these cancers were smaller than symptomatic thyroid cancers. Still, some asymptomatic cancers were large, consistent with historic data. The substantial difference in MOD patterns among the 4 countries suggests extensive variations in practice.

American Head and Neck Society Endocrine Surgery Section and International Thyroid Oncology Group consensus statement on mutational testing in thyroid cancer: Defining advanced thyroid cancer and its targeted treatment

BACKGROUND

The development of systemic treatment options leveraging the molecular landscape of advanced thyroid cancer is a burgeoning field. This is a multidisciplinary evidence-based statement on the definition of advanced thyroid cancer and its targeted systemic treatment.

METHODS

An expert panel was assembled, a literature review was conducted, and best practice statements were developed. The modified Delphi method was applied to assess the degree of consensus for the statements developed by the author panel.

RESULTS

A review of the current understanding of thyroid oncogenesis at a molecular level is presented and characteristics of advanced thyroid cancer are defined. Twenty statements in topics including the multidisciplinary management, molecular evaluation, and targeted systemic treatment of advanced thyroid cancer are provided.

CONCLUSIONS

With the growth in targeted treatment options for thyroid cancer, a consensus definition of advanced disease and statements regarding the utility of molecular testing and available targeted systemic therapy is warranted.

Pediatric intraoperative nerve monitoring during thyroid surgery: A review from the American Head and Neck Society Endocrine Surgery Section and the International Neural Monitoring Study Group

Children are more likely to experience recurrent laryngeal nerve (RLN) injury during thyroid surgery. Intraoperative nerve monitoring (IONM) may assist in nerve identification and surgical decision making. A literature review of pediatric IONM was performed and used to inform a monitoring technique guide and expert opinion statements. Pediatric IONM is achieved using a variety of methods. When age-appropriate endotracheal tubes with integrated surface electrodes are not available, an alternative method should be used. Patient age and surgeon experience with laryngoscopy influence technique selection; four techniques are described in detail. Surgeons must be familiar with the nuances of monitoring technique and interpretation; opinion statements address optimizing this technology in children. Adult IONM guidelines may offer strategies for surgical decision making in children. In some cases, delay of second-sided surgery may reduce bilateral RLN injury risk.

Breast and thyroid cancer: A multicenter study with Accrual to Clinical Trials Network

OBJECTIVE

To investigate a possible link between breast and thyroid cancer.

METHODS

A multicenter retrospective review of patients in the electronic medical records of six Accrual to Clinical Trial (ACT) institutions with both breast cancer and thyroid carcinoma. Each center queried its data using a predefined data dictionary. Information on thyroid and breast cancer included dates of diagnosis, histology, and patient demographics.

RESULTS

A random-effects model was used. There were 4.24 million women's records screened, 44 605 with breast cancer and 11 846 with thyroid cancer. The relative risks observed at each institution ranged from 0.49 to 13.47. The combined risk ratio (RR) estimate was 1.77 (95% confidence interval: 0.50-5.18).

CONCLUSION

There was no association between the risk of developing thyroid cancer and being a breast cancer survivor compared to no history of breast cancer, but the range of relative risks among the participating institutions was wide. Our findings warrant further study of more institutions with larger sample size. Additionally, further analysis of the significance of regional RR differences may be enlightening.

Outcomes in Pediatric Thyroidectomy: Results From a Multinational, Multi-institutional Database

OBJECTIVE

Traditionally, data regarding thyroidectomy were extracted from billing databases, but information may be missed. In this study, a multi-institutional pediatric thyroidectomy database was used to evaluate recurrent laryngeal nerve (RLN) injury and hypoparathyroidism.

STUDY DESIGN

Retrospective multi-institutional cohort study.

SETTING

Tertiary care pediatric hospital systems throughout North America.

METHODS

Data were individually collected for thyroidectomies, then entered into a centralized database and analyzed using univariate and multivariable regression models.

RESULTS

In total, 1025 thyroidectomies from 10 institutions were included. Average age was 13.9 years, and 77.8% were female. Average hospital stay was 1.9 nights and 13.5% of patients spent at least 1 night in the pediatric intensive care unit. The most frequent pathology was papillary thyroid carcinoma (42%), followed by Graves' disease (20.1%) and follicular adenoma (18.2%). Overall, 1.1% of patients experienced RLN injury (0.8% permanent), and 7.2% experienced hypoparathyroidism (3.3% permanent). Lower institutional volume (odds ratio [OR], 3.57; 95% CI, 1.72-7.14) and concurrent hypoparathyroidism (OR, 3.51; 95% CI, 1.64-7.53) correlated with RLN injury on multivariable analysis. Graves' disease (OR, 2.27; 95% CI, 1.35-3.80), Hashimoto's thyroiditis (OR, 4.67; 95% CI, 2.39-9.09), central neck dissection (OR, 3.60; 95% CI, 2.36-5.49), and total vs partial thyroidectomy (OR, 7.14; 95% CI, 4.55-11.11) correlated with hypoparathyroidism.

CONCLUSION

These data present thyroidectomy information and complications pertinent to surgeons, along with preoperative risk factor assessment. Multivariable analysis showed institutional volume and hypoparathyroidism associated with RLN injury, while hypoparathyroidism associated with surgical indication, central neck dissection, and extent of surgery. Low complication rates support the safety of thyroidectomy in pediatric tertiary care centers.

Machine learning can identify patients at risk of hyperparathyroidism without known calcium and intact parathyroid hormone

BACKGROUND

To prove the concept of diagnosing primary hyperparathyroidism (pHPT) without calcium and parathyroid hormone (PTH) values and identifying potential risk factors for pHPT.

METHODS

Data were extracted from the clinical data warehouse (CDW) at the University of Arkansas for Medical Sciences (UAMS) Epic EHR (2014-2019).

RESULTS

1737 patients with over 185 000 rows of clinical data were provided in a relational structure and processed/flattened to facilitate modeling. Phenotype elements were identified for pHPT without advance knowledge of calcium and PTH levels. The area under the curve (AUC) for the prediction of pHPT using our model was 0.86 with sensitivity and specificity of 0.8953 and 0.6686, respectively, using a 0.45 probability threshold.

CONCLUSION

Primary hyperparathyroidism was predicted from a dataset excluding calcium and PTH data with 86% accuracy. This approach needs to be validated/refined on larger samples of data and plans are in place to do this with other regional/national datasets.

Radiofrequency ablation and related ultrasound-guided ablation technologies for treatment of benign and malignant thyroid disease: An international multidisciplinary consensus statement of the American Head and Neck Society Endocrine Surgery Section with the Asia Pacific Society of Thyroid Surgery, Associazione Medici Endocrinologi, British Association of Endocrine and Thyroid Surgeons, European Thyroid Association, Italian Society of Endocrine Surgery Units, Korean Society of Thyroid Radiology, Latin American Thyroid Society, and Thyroid Nodules Therapies Association

BACKGROUND

The use of ultrasound-guided ablation procedures to treat both benign and malignant thyroid conditions is gaining increasing interest. This document has been developed as an international interdisciplinary evidence-based statement with a primary focus on radiofrequency ablation and is intended to serve as a manual for best practice application of ablation technologies.

METHODS

A comprehensive literature review was conducted to guide statement development and generation of best practice recommendations. Modified Delphi method was applied to assess whether statements met consensus among the entire author panel.

RESULTS

A review of the current state of ultrasound-guided ablation procedures for the treatment of benign and malignant thyroid conditions is presented. Eighteen best practice recommendations in topic areas of preprocedural evaluation, technique, postprocedural management, efficacy, potential complications, and implementation are provided.

CONCLUSIONS

As ultrasound-guided ablation procedures are increasingly utilized in benign and malignant thyroid disease, evidence-based and thoughtful application of best practices is warranted.

Clarifying optimal outcome measures in intermittent and continuous laryngeal neuromonitoring

BACKGROUND

Intraoperative neuromonitoring (IONM) techniques have evolved over the past decade into intermittent IONM (I-IONM) and continuous IONM (C-IONM) modes of application. Despite many prior publications on both types of IONM, there remains uncertainty about what outcomes should be measured for each form of IONM. The primary objective of this paper is to define categories of benefit for I-IONM/C-IONM and to clarify and standardize their reporting outcomes.

METHODS

Expert review consensus statement utilizing modified Delphi methodology.

RESULTS

I-IONM provides diagnosis, classification, and prevention of nerve injury through accurate and early nerve identification. C-IONM provides real-time information on nerve functional integrity and thus may prevent some types of nerve injury but cannot assist in nerve localization. Sudden mechanisms of nerve injury cannot be predicted or prevented by either technique.

CONCLUSIONS

I-IONM and C-IONM are complementary techniques. Future studies evaluating the utility of IONM should focus on outcomes that are appropriate to the type of IONM being utilized.

Trends in Diagnosis of Noninvasive Follicular Thyroid Neoplasm With Papillarylike Nuclear Features and Total Thyroidectomies for Patients With Papillary Thyroid Neoplasms

Importance

Increasing detection of early-stage papillary thyroid neoplasms without improvements in mortality has prompted development of strategies to prevent or mitigate overtreatment.

Objective

To determine adoption rates of 2 recent strategies developed to limit overtreatment of low-risk thyroid cancers: (1) a new classification, noninvasive follicular thyroid neoplasm with papillarylike nuclear features (NIFTP), and (2) hemithyroidectomy for selected papillary thyroid carcinomas (PTCs) up to 4 cm in size.

Design, Setting, and Participants

This is a cross-sectional analysis of 3368 pathology records of 2 cohorts of patients from 18 hospitals in 6 countries during 2 time periods (2015 and 2019). Participating hospitals were included from the US (n = 12), Canada (n = 2), Denmark (n = 1), South Korea (n = 1), South Africa (n = 1), and India (n = 1). The records of the first 100 patients per institution for each year who underwent thyroid-directed surgery (hemithyroidectomy, total thyroidectomy, or completion thyroidectomy) were reviewed.

Main Outcomes and Measures

Frequency of diagnosis of NIFTP, PTCs, and thyroidectomies during the study period.

Results

Of the 790 papillary thyroid neoplasms captured in the 2019 cohort, 38 (4.8%) were diagnosed as NIFTP. Diagnosis of NIFTP was observed in the US, South Africa, and India. There was minimal difference in the total proportion of PTCs in the 2015 cohort compared with the 2019 cohort (778 [47.1%] vs 752 [44.5%]; difference, 2.6% [95% CI, -16.9% to 22.1%]). The proportion of PTCs eligible for hemithyroidectomy but treated with total thyroidectomy in the 2 cohorts demonstrated a decreasing trend from 2015 to 2019 (341 of 453 [75.3%] vs 253 of 434 [58.3%]; difference, 17.0% [95% CI, -1.2% to 35.2%]).

Conclusions and Relevance

Results of this cohort study showed that the 2 mitigation strategies for preventing overtreatment of early-stage thyroid cancer have had mixed success. The diagnosis of NIFTP has only been applied to a small proportion of thyroid neoplasms compared with expected rates. However, more patients eligible for hemithyroidectomy received it in 2019 compared with 2015, showing some success with this deescalation strategy.

Afirma Genomic Sequencing Classifier and Xpression Atlas Molecular Findings in Consecutive Bethesda III-VI Thyroid Nodules

CONTEXT

Broad genomic analyses among thyroid histologies have been described from relatively small cohorts.

OBJECTIVE

Investigate the molecular findings across a large, real-world cohort of thyroid fine-needle aspiration (FNA) samples.

DESIGN

Retrospective analysis of RNA sequencing data files.

SETTING

Clinical Laboratory Improvement Amendments laboratory performing Afirma Genomic Sequencing Classifier (GSC) and Xpression Atlas (XA) testing.

PARTICIPANTS

A total of 50 644 consecutive Bethesda III-VI nodules.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Molecular test results.

RESULTS

Of 48 952 Bethesda III/IV FNAs studied, 66% were benign by Afirma GSC. The prevalence of BRAF V600E was 2% among all Bethesda III/IV FNAs and 76% among Bethesda VI FNAs. Fusions involving NTRK, RET, BRAF, and ALK were most prevalent in Bethesda V (10%), and 130 different gene partners were identified. Among small consecutive Bethesda III/IV sample cohorts with one of these fusions and available surgical pathology excision data, the positive predictive value of an NTRK or RET fusion for carcinoma or noninvasive follicular thyroid neoplasm with papillary-like nuclear features was >95%, whereas for BRAF and ALK fusions it was 81% and 67%, respectively. At least 1 genomic alteration was identified by the expanded Afirma XA panel in 70% of medullary thyroid carcinoma classifier-positive FNAs, 44% of Bethesda III or IV Afirma GSC suspicious FNAs, 64% of Bethesda V FNAs, and 87% of Bethesda VI FNAs.

CONCLUSIONS

This large study demonstrates that almost one-half of Bethesda III/IV Afirma GSC suspicious and most Bethesda V/VI nodules had at least 1 genomic variant or fusion identified, which may optimize personalized treatment decisions.

Utility of intraoperative digital scintigraphy in radioguided parathyroidectomy

BACKGROUND

Intraoperative scintigraphy (IoS) has been proposed as a tool for real-time intraoperative decision-making regarding parathyroid adenoma localization and confirmation of excision.

METHODS

Retrospective review of patients who underwent minimally invasive parathyroidectomies with scintigraphy performed intraoperatively. Preoperative neck ultrasound, 4D computed tomography, as well as intraoperative parathyroid hormone (IOPTH) and gamma probe measurements were conducted per standard practice. IoS images were obtained prior to and following parathyroid excision. Cases were reviewed to determine accuracy of IoS for localizing parathyroid pathology and confirming successful excision.

RESULTS

Fifty-six cases met the inclusion criteria. Twenty-nine patients (51.8%) showed confirmation of excision of an abnormal gland on post-excision IoS. There were no significant differences in IOPTH reduction and postoperative laboratory values between patients with IoS-identified resolution and those without IoS-identified resolution.

CONCLUSIONS

With low accuracy in correctly localizing abnormal glands and confirming their excision, there is no appreciable benefit of IoS at this time.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement

BACKGROUND

This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking.

METHODS

An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements.

CONCLUSIONS

This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

Rapid telehealth implementation into an otolaryngology practice during the COVID-19 pandemic

OBJECTIVE

Report outcomes of rapid implementation of telehealth across an academic otolaryngology-head and neck surgery department during the COVID-19 pandemic.

METHODS

This is a retrospective, single-institution study of rapid deployment of telehealth during the COVID-19 pandemic. Characteristics of patients were compared between those who agreed and those who declined telehealth care. Reasons for declining telehealth visits were ascertained. Characteristics of telehealth visits were collected and patients were asked to complete a post-visit satisfaction survey.

RESULTS

There was a 68% acceptance rate for telehealth visits. In multivariable analysis, patients were more likely to accept telehealth if they were being seen in the facial plastics subspecialty clinic (odds ratio [OR] 59.55, 95% confidence interval [CI] 2.21-1607.52; P = .015) compared to the general otolaryngology clinic. Patients with Medicare (compared to commercial insurance) as their primary insurance were less likely to accept telehealth visits (OR 0.10, 95% CI 0.01-0.77; P = .027). Two hundred and thirty one patients underwent telehealth visits; most visits (69%) were for established patients and residents were involved in 38% of visits. There was an 85% response rate to the post-visit survey. On a scale of one to ten, the median satisfaction score was 10 and 99% of patients gave a score of 8 or higher. Satisfaction scores were higher for new patient visits than established patient visits (P = .020).

CONCLUSION

Rapid implementation of telehealth in an academic otolaryngology-head and neck surgery department is feasible. There was high acceptance of and satisfaction scores with telehealth.

LEVEL OF EVIDENCE

3.

NTRK, RET, BRAF, and ALK fusions in thyroid fine-needle aspirates (FNAs)

6083

Background: Receptor tyrosine kinase (RTK) fusions may be targeted by small molecule inhibitors to treat various advanced tumors, including thyroid cancer. Clinical trials have studied selective inhibitors of ALK, BRAF, NTRK and RET, leading to several FDA-approved therapies. The Afirma Genomic Sequencing Classifier (GSC) classifies cytologically indeterminate thyroid nodules as molecularly benign or suspicious. The Xpression Atlas reports 905 genomic variants and 235 fusion pairs on GSC Suspicious, Suspicious for Malignancy (SFM), and Malignant FNA samples at the time of diagnosis. Here we report the prevalence of these fusion genes in real-world clinical practice. Methods: We analyzed anonymized data from 50,644 consecutive Bethesda III-VI nodule FNA samples submitted to the Veracyte CLIA laboratory for molecular testing using whole transcriptome RNA sequencing (RNA-Seq). Gene pairs are listed alphabetically. Results: 32,080 Bethesda III/IV nodules were classified as GSC Benign and 278 were Parathyroid Classifier positive. No ALK, BRAF, NTRK1/3, or RET fusions were identified among these samples. Among 16,594 Bethesda III/IV GSC Suspicious FNAs, 3% (n = 529) were positive for ALK, BRAF, NTRK1/3 or RET fusions. Among the 1,692 Bethesda V/VI FNAs, the proportion of positive nodules was 8% (n = 135). Among these combined cohorts of Bethesda III/IV GSC Suspicious and Bethesda V/VI, the most common gene fusions observed for each of the 5 studied RTK genes was: ETV6/NTRK3 (n = 164, 72% of NTRK3 fusions), CCDC6/RET (n = 104, 55% of RET), BRAF/SND1 (n = 32, 20% of BRAF), ALK/STRN (n = 20, 37% of ALK), and NTRK1/TPM3 (n = 14, 50% of NTRK1). BRAF showed the highest diversity of fusions, with 80 gene partners. Different gene partners with RET, ALK, NTRK1, and NTRK3 numbered 25, 11, 9, and 5 , respectively . Conclusions: Whole-transcriptome RNA-seq on small sample thyroid FNA specimens can identify clinically relevant ALK, BRAF, NTRK, and RET fusions across Bethesda categories. The prevalence ranges from 3% in Bethesda III/IV Afirma GSC Suspicious specimens to 8% among Bethesda V/VI specimens. Future studies need to determine if detection of precision medicine candidates by pre-operative FNA can optimize initial treatment, predict response to treatment, and prioritize selective targeted therapy should systemic treatment be needed.[Table: see text]

Development and Assessment of an Otolaryngology-Specific Surgical Priority Scoring System

Objective

To develop and assess an otolaryngology-specific surgical priority scoring system that incorporates varying levels of mucosal involvement.

Study Design

Retrospective cohort.

Setting

Academic medical center.

Methods

A novel mucosal score was developed based on best available evidence. This mucosal score was incorporated into the Medically Necessary, Time-Sensitive (MeNTS) score to generate a MeNTS-Mucosal (MeNTS-M) score. A retrospective cohort of patients was identified to assess the surgical priority scoring systems. Inclusion criteria included all scheduled surgical procedures between March 23, 2020, and April 17, 2020. Decisions about whether to proceed or cancel were made based on best clinical judgment by surgeons, without use of any surgical priority scores. The predictive value of the surgical priority scoring systems was assessed in this retrospective cohort.

Results

The median MeNTS score was significantly lower in adult patients whose surgery proceeded compared to those for whom the surgery was cancelled (48 vs 56; P = .004). Mucosal and MeNTS-M scores were not statistically different based on whether surgery proceeded. Among adult patients, the highest area under the curve (AUC) was for the MeNTS scoring system (0.794); both the mucosal and MeNTS-M systems had lower AUC values (which were significantly lower than the AUC for the MeNTS scoring system).

Conclusion

This study represents development and assessment of the first otolaryngology-specific surgical priority score and incorporates varying levels of mucosal disruption. The combined MeNTS-M scoring system could be a valuable tool in appropriately triaging otolaryngology–head and neck surgery procedures.

Predictors for Postoperative Chyle Leak Following Neck Dissection, a Technique-Based Comparison

OBJECTIVE

Assess the impact of surgical technique used to address level IV on the rate of postoperative chyle leak.

STUDY DESIGN

Retrospective chart review.

SETTING

Academic tertiary care center.

METHODS

An analysis of 436 consecutive neck dissections (NDs) in 368 patients was performed by 3 head and neck surgeons between 2014 and 2017. Variation in technique reflects individual approaches to the management of level IV and included suture ligation (SL), monopolar electrocautery (MC), and harmonic scalpel transection (HS). Data points included patient demographics, surgical technique, intraoperative findings, postoperative chyle leaks, and leak management. Correlation between variables was analyzed through χ² test and Student t test with statistical α set at .05.

RESULTS

Overall, 12 patients (3.2%) developed chyle leaks postoperatively. Nine of 12 and 3 of 12 presented with left- and right-sided leaks, respectively. Five of 12 leaks occurred following bilateral ND, 5 of 12 following left ND, and 2 of 12 following right ND. Univariate analysis showed a statistically significant difference (P = .001) favoring SL (1.0%) and MC (1.2%) techniques over the HS technique (8.6%). A statistically significant increase existed in the rate of leak with endocrine vs nonendocrine pathology (P = .003). Average duration of leak was 13.3 ± 13.5 days. Management included diet modification (n = 11, 91.6%), pressure-dressing placement (n = 7, 58.3%), and octreotide (n = 5, 41.7%). No cases required reoperation, and no mortality or severe malnutrition was observed in this series.

CONCLUSIONS

SL and MC techniques demonstrated superiority over the HS technique in preventative management of chyle leak in level IV, with a significantly higher rate of chyle leak observed in endocrine-related pathology.

Opioid reduction in ambulatory thyroid and parathyroid surgery after implementing enhanced recovery after surgery protocol

BACKGROUND

Opioid abuse is widespread in the United States and the risk for chronic use is increased in surgical patients, including patients with thyroid and parathyroid.

METHODS

Records for 171 patients prior to and 67 patients following implementation of an enhanced recovery after surgery (ERAS) protocol for ambulatory thyroid/parathyroid surgeries were reviewed. The ERAS included superficial cervical plexus block, multimodal premedication, and postoperative reliance on acetaminophen and ibuprofen with judicious prescribing of opioids.

RESULTS

Post-ERAS patients were prescribed a mean 72 morphine milligram equivalents (MME); pre-ERAS patients were prescribed a mean 163 MME (p < 0.001). 97.1% of pre-ERAS patients were prescribed opioids with 91.1% filled; 68.7% of post-ERAS study patients were prescribed opioids with 84.8% filled.

CONCLUSION

Implementation of ERAS and focus on prescribing practices decreased the MME prescribed and used for ambulatory thyroid and parathyroid surgery. Future steps include increased patient education and tracking pain scores and medication utilization out of hospital.

Normocalcemic and Normohormonal Primary Hyperparathyroidism: Laboratory Values and End-Organ Effects

OBJECTIVE

Variants of primary hyperparathyroidism (pHPT), described as normocalcemic (NC) and normohormonal (NH), can confuse the diagnosis of classic pHPT.

DATA SOURCES

A MEDLINE search was performed for variants of pHPT using the PubMed database (last queried October 2019).

REVIEW METHODS

The search was restricted to articles published after 1960 that were specific to humans. Studies were included in our analysis if laboratory values and incidence of end-organ involvement were reported for NCpHPT and NHpHPT variants. The search returned 189 articles; 27 additional studies were identified and included for a total of 216. Non-English-language studies were excluded. Abstracts were screened, full-text articles were then assessed, and 82 articles were excluded. Data were pooled using a random-effects model in studies that compared NC or NH pHPT to classic pHPT. Comparative laboratory values are presented.

CONCLUSION

This analysis compares NCpHPT and NHpHPT to classic pHPT. Nephrolithiasis was 21.7% (NCpHPT), 15.9% (classic pHPT), and 25.4% (NHpHPT). Decreased bone mineral density was 49.7% (NCpHPT), 39.7% (classic pHPT), and 40.3% (NHpHPT). Fractures in the NCpHPT group were not significantly different from the classic pHPT. Hypertension in the NCpHPT group was significantly less than classic pHPT (odds ratio, 0.59; 95% CI, 0.40-0.88).

IMPLICATIONS FOR CLINICAL PRACTICE

This information may serve to inform clinicians of the laboratory subtleties of these variants that are being seen with greater frequency in contemporary practice.

Consensus statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS-ES) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Consensus Statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

FDG-PET/CT and Pathology in Newly Diagnosed Head and Neck Cancer: ACRIN 6685 Trial, FDG-PET/CT cN0

OBJECTIVE

FDG-PET/CT (fluorodeoxyglucose-positron emission tomography/computed tomography) is effective to assess for occult neck nodal disease. We report risks and patterns of nodal disease based on primary site and nodal level from data on the dissected cN0 per the results from ACRIN 6685.

STUDY DESIGN

Prospective nonrandomized enrollment included participants with first-time head and neck squamous cell carcinoma and at least 1 cN0 neck side to be dissected.

SETTING

Twenty-four ACRIN-certified centers internationally (American College of Radiology Imaging Network).

METHODS

A total of 287 participants were enrolled. Preoperative FDG-PET/CT findings were centrally reviewed and compared with pathology. Incidence, relative risk, pattern of lymph node involvement, and impact upon neck dissection were reported.

RESULTS

An overall 983 nodal levels were dissected (n = 261 necks, n = 203 participants). The highest percentages of ipsilateral positive nodes by primary location and nodal level were oral cavity (level I, 17/110, 15.5%), pharynx (level II, 6/30, 20.0%), and larynx (level VI, 1/3, 33.3%).

CONCLUSION

Levels at greatest risk for nodal disease in cN0 in terms of ipsilateral neck dissection are level I (oral cavity), II (pharynx), and VI (larynx). These data should be considered when treating patients presenting with cN0. This is the first study to comprehensively report the incidence, location, and risk of metastases in cN0 in the FDG-PET/CT era.

AHNS endocrine surgery section consensus statement on nasopharyngolaryngoscopy and clinic reopening during COVID-19: How to get back to optimal safe care

This article provides best practice guidelines regarding nasopharyngolaryngoscopy and OHNS clinic reopening during the COVID-19 pandemic. The aim is to provide evidence-based recommendations defining the risks of COVID-19 in clinic, the importance of pre-visit screening in addition to testing, along with ways to adhere to CDC guidelines for environmental, source, and engineering controls.

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment

BACKGROUND

Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group.

METHODS

A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach.

RESULTS

Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery.

CONCLUSION

After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.

Assessment of operative competency for thyroidectomy: Comparison of resident self-assessment vs attending surgeon assessment

BACKGROUND

Self-awareness of skill, essential for progression as a surgeon, has direct bearing on postresidency practice; however, studies have supported that residents achieve self-perceived competence later than believed by program directors. This study compares residents' self-perception of operative competency to attending surgeon's evaluation using Computer Enhanced Visual Learning, a validated online hemithyroidectomy-specific assessment tool.

METHODS

Eleven otolaryngology-Head and Neck Surgery (HNS) residents completed a preoperative module and postoperative survey, later reviewed by an attending surgeon. Eighty-three performances were assessed for inter-rater reliabilities of key surgical steps.

RESULTS

Almost perfect agreement (Kappa = 0.81-1.00) was shown in 11 of 18 parameters. Substantial agreement (Kappa = 0.61-0.80) was demonstrated in the remaining seven parameters.

CONCLUSIONS

Otolaryngology-HNS trainees have high self-awareness of their performance at each step in a hemithyroidectomy. Standardized assessment tools can allow for documentation of procedural performance and serve as guides for improvement. This is the only study to examine otolaryngology-HNS trainees' self-perceived skill compared to an attending surgeon's assessment for hemithyroidectomy.

Salivary and lacrimal dysfunction after radioactive iodine for differentiated thyroid cancer: American Head and Neck Society Endocrine Surgery Section and Salivary Gland Section joint multidisciplinary clinical consensus statement of otolaryngology, ophthalmology, nuclear medicine and endocrinology

BACKGROUND

Postoperative radioactive iodine (RAI) administration is widely utilized in patients with differentiated thyroid cancer. While beneficial in select patients, it is critical to recognize the potential negative sequelae of this treatment. The prevention, diagnosis, and management of the salivary and lacrimal complications of RAI exposure are addressed in this consensus statement.

METHODS

A multidisciplinary panel of experts was convened under the auspices of the American Head and Neck Society Endocrine Surgery and Salivary Gland Sections. Following a comprehensive literature review to assess the current best evidence, this group developed six relevant consensus recommendations.

RESULTS

Consensus recommendations on RAI were made in the areas of patient assessment, optimal utilization, complication prevention, and complication management.

CONCLUSION

Salivary and lacrimal complications secondary to RAI exposure are common and need to be weighed when considering its use. The recommendations included in this statement provide direction for approaches to minimize and manage these complications.

The Utility of the Cl:PO4 Ratio in Patients With Variant Versions of Primary Hyperparathyroidism

OBJECTIVE

To determine the significance and impact of additional chloride testing as part of a diagnostic laboratory test battery for borderline primary hyperparathyroidism (pHPT).

STUDY DESIGN

Retrospective database review of parathyroidectomy patients.

SETTING

A tertiary care, academic health sciences center.

SUBJECTS AND METHODS

Patients referred to a head and neck endocrine clinic for evaluation and treatment for pHPT.

RESULTS

After exclusions, there were a total of 226 patients who underwent parathyroidectomy for primary hyperparathyroidism with the requisite preoperative and postoperative labs. Seventy-seven additional patients who had a thyroid operation for a nonmalignant cause were included as controls. Of the 303 total patients, 166 had normal calcium levels (<10.4 mg/dL), and 54 (32.5%) also exhibited hyperchloremia (>106 mmol/L). Of the 47 patients with normal calcium and parathyroid hormone (PTH) levels (<88 pg/mL), 6 (12.8%) had hyperchloremia, and of the 118 patients with normocalcemic pHPT, 48 (40.7%) were hyperchloremic. The area under the curve for the Cl:PO4 was 0.712. When using a cutoff of 33, the reported sensitivity and specificity of the curve were 58.4% and 28.6%, respectively.

CONCLUSION

The Cl:PO4 ratio was a moderately sensitive test for the diagnosis of the borderline variants of primary hyperparathyroidism. The Ca:PO4 ratio was superior to the Cl:PO4 ratio. Our data also showed the superiority of preoperative calcium and ionized calcium over PTH when predicting the presence of pHPT.

Investigating the potential underdiagnosis of primary hyperparathyroidism at the University of Arkansas for Medical Sciences

INTRODUCTION

Primary hyperparathyroidism (PHPT) is a condition in which one or more parathyroid glands secrete excess amounts of parathyroid hormone (PTH). In short, PHPT is characterized by hypercalcemia/hypercalciuria with concurrent elevated PTH levels. This condition is known to increase the risk of cardiovascular disease, osteoporosis, psychiatric disturbances, and renal complications. As of now, the disease typically runs a long course before being identified and treated. At present, surgery is the only viable treatment option for patients with this disease. Publications from other tertiary centers have identified a large-scale underdiagnosis of PHPT. The aim of this study is to determine if similar trends exist at the University of Arkansas for Medical Sciences (UAMS). Moreover, this study was seen as a first step to developing a machine learning strategy to diagnose PHPT in large clinical data sets.

METHODS

To evaluate for potential underdiagnosis of PHPT at UAMS, all patients from 2006 to 2018 with hypercalcemia and/or hypercalciuria (excluding those with known malignancies or other possible causes of excess serum calcium) were identified in electronic medical records. Then, it was evaluated whether these hypercalcemic/hypercalciuric patients received subsequent measurement of PTH levels necessary to confirm the diagnosis of HPT.

RESULTS

At UAMS between 2006 and 2018, 28 831 patients were identified as having hypercalcemia and/or hypercalciuria. Of these patients, only 7984 ever had subsequent PTH levels tested. Therefore, 20 847 (72.3%) of these patients never had PTH labs drawn.

CONCLUSIONS

These findings may represent a significant patient population in which PHPT remains undiagnosed due to lack of follow-up. PHPT is often a silent disease with an insidious onset. At the point of diagnosis, typically the treatment is surgical removal of the offending parathyroid gland(s) (parathyroidectomy). Identification of underdiagnosis is the first step for subsequent improvement in the diagnosis of PHPT. Detection of this disease in its earlier stages may open the door for medical and lifestyle interventions, thereby decreasing long-term sequelae of the disease, such as osteoporosis, myocardial infarction, or stroke.

Abstract B24: A rationale for screening for thyroid malignancy in breast cancer patients

Introduction: An increased incidence of thyroid cancer in breast cancer patients has been demonstrated in the literature. A recent meta-analysis reports odds ratio of developing thyroid cancer after breast cancer to be 1.55 (Nielsen et al., 2016). The USPSTF and ATA recommend against routine thyroid screening for non-high-risk asymptomatic adults. We aim to obtain demographics of breast cancer patients who develop thyroid cancer and assess their malignancies. We use this assessment to discuss the potential impact that routine thyroid screening could have on breast cancer patients.

Methods: We performed a literature review using PubMed and Web of Science databases and reviewed abstracts of 352 publications. Papers were excluded for nonrelevance or lack of patient-level data. Relevant papers were fully reviewed and their data were compared to population-level data from the SEER database. We then gathered data on breast cancer patients at our home institution who later developed thyroid cancer. Chart review was performed on medical records with relevant diagnostic codes. Exclusions were made for nonrelevance or lack of information. Patient demographics and breast and thyroid cancer characteristics were obtained.

Results: In literature review four papers were used to obtain breast cancer characteristics on 206 patients. Mean age of breast cancer diagnosis (47.07 years) was younger than peak incidence age range for breast cancer reported by SEER registry (75-79 years). There were more patients with ductal carcinoma in situ or infiltrating ductal carcinoma compared to SEER population (97.09% vs. 74.33). Estrogen receptor status was positive less often compared to SEER population (73.23% vs. 80.77). Five papers were used to obtain thyroid cancer characteristics on 230 patients. Mean tumor size was smaller compared to the SEER population (1.017 cm vs. 1.782). There was a higher percentage of nodal involvement (25.90% vs. 19.62) and extrathyroid extension (34.98% vs. 15.37) compared to SEER population. Initial search for home institution breast cancer patients later developing thyroid cancer yielded 108 patients. 39 were included in our study. The majority developed papillary thyroid cancer with a mean tumor size of 0.99 cm. 74.4% were treated with total thyroidectomy.

Conclusion: Screening for thyroid malignancy is a contentious topic. Speculation of the impact thyroid cancer screening could have for breast cancer patients has prompted us to identify the characteristics of these patients and their cancers. Literature review suggests that these patients may develop thyroid cancers with increased lymphovascular involvement and increased extrathyroid extension. If true, it may be worth considering a change in thyroid cancer screening guidelines for female breast cancer patients. Current work is focused on developing more definitive conclusions. We are performing a more in-depth chart review and developing a data collaboration via the Southeastern SHRINE research network to gather more data.

Citation Format: Brendan C. Stack, Edouard M. Oudin. A rationale for screening for thyroid malignancy in breast cancer patients [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr B24.

MON-LB88 Positive Predictive Value of TP53 Variants in Bethesda III/IV Thyroid Fine-Needle Aspirates

Introduction: Somatic DNA variants in the tumor suppressor gene TP53 have been reported in papillary thyroid carcinoma (PTC), Hürthle cell carcinoma (HCC), poorly differentiated thyroid cancer (PDTC), and anaplastic thyroid carcinoma. However, TP53 variants are uncommon among cytologically indeterminate thyroid nodules, so their positive predictive value (PPV) for malignancy, when identified, is unknown. The original Afirma Xpression Atlas reported genomic variants from the mRNA of 511 genes, including TP53. Here we report the PPV of TP53 alterations among Afirma Genomic Sequencing Classifier (GSC) Suspicious Bethesda III/IV nodules in real-world clinical practice.

Methods: A consecutive cohort of Afirma GSC Suspicious Bethesda III/IV nodules submitted to Veracyte for molecular analysis and positive for only TP53 alterations by the Xpression Atlas was identified. Local surgical pathology diagnoses were sought with IRB approval. One nodule per patient was included.

Results: Thirty-eight TP53 variants were present among >13,000 Bethesda III/IV Afirma GSC Suspicious samples. Among the 22 with only a TP53 alteration, the first 16 consecutive nodules were included (7 nodules were Bethesda III and 9 nodules were Bethesda IV). Local surgical pathology diagnoses were available for 11 of these nodules. Seven nodules (64%) were malignant on surgical pathology: 3 cases of HCC, 1 PDTC, 1 follicular thyroid carcinoma (FTC), 1 follicular variant PTC, and 1 classical PTC. The mean size of malignant nodules was 3.6 cm (range 1-7.7 cm). The remaining four nodules (36%) were benign on surgical pathology, with a mean size of 2.6 cm (range 1.5-4.2 cm). Benign cases included 2 follicular adenomas (FA), 1 Hürthle cell adenoma (HCA), and 1 adenomatoid nodule (AN). Seven different TP53 variants were identified, and only one was observed at least 3 times (TP53: p.R248Q in 2 cases of HCC and 1 adenomatoid nodule). Given the small numbers, meaningful estimates of the variants’ individual PPVs could not be calculated.

Conclusions:TP53 variants among Afirma GSC Suspicious Bethesda III/IV nodules are very rare and associated with malignancy in 64% of nodules based on local pathology review. A broad range of both benign and malignant neoplasms, including HCC, PDTC, FTC, PTC, FA, HCA, and AN, were reported among nodules with TP53 alterations. The prognostic value of finding an isolated TP53 variant in Afirma Suspicious nodules remains unknown.

American Head and Neck Society Endocrine Surgery Section update on parathyroid imaging for surgical candidates with primary hyperparathyroidism

Health care consumer organizations and insurance companies increasingly are scrutinizing value when considering reimbursement policies for medical interventions. Recently, members of several American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) committees worked closely with one insurance company to refine reimbursement policies for preoperative localization imaging in patients undergoing surgery for primary hyperparathyroidism. This endeavor led to an AAO-HNS parathyroid imaging consensus statement (https://www.entnet.org/content/parathyroid-imaging). The American Head and Neck Society Endocrine Surgery Section gathered an expert panel of authors to delineate imaging options for preoperative evaluation of surgical candidates with primary hyperparathyroidism. We review herein the current literature for preoperative parathyroid localization imaging, with discussion of efficacy, cost, and overall value. We recommend that planar sestamibi imaging, single photon emission computed tomography (SPECT), SPECT/CT, CT neck/mediastinum with contrast, MRI, and four dimensional CT (4D-CT) may be used in conjunction with high-resolution neck ultrasound to preoperatively localize pathologic parathyroid glands. PubMed literature on parathyroid imaging was reviewed through February 1, 2019.

Multicenter Trial of [18F]fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Staging of Head and Neck Cancer and Negative Predictive Value and Surgical Impact in the N0 Neck: Results From ACRIN 6685

PURPOSE

The objective of this study was to determine the negative predictive value (NPV) of positron emission tomography (PET)/computed tomography (CT) for the clinically N0 neck on the basis of neck dissection.

METHODS

Participants with newly diagnosed, first-time, head and neck squamous cell carcinoma (HNSCC) and at least one clinically N0 neck side for which dissection was planned were included. A total of 287 participants were prospectively enrolled from 23 American College of Radiology Imaging Network-qualified institutions. PET/CT was compared with findings at neck dissection.

RESULTS

PET/CT scans and pathology findings were available for 270 N0 neck sides from 212 participants. For visual assessment, the NPV specific to the clinical-N0 sides was 0.868 (95% CI, 0.803 to 0.925). For dichotomized maximum standardized uptake value, the NPVs specific to the nodal basins were 0.940 (95% CI, 0.928 to 0.952) and 0.937 (95% CI, 0.925 to 0.949) at prespecified cutoffs of 2.5 and 3.5, respectively. The optimal cutoff maximum standardized uptake value was determined to be 1.8, with an NPV of 0.942 (95% CI, 0.930 to 0.953). The PET/CT-informed surgical treatment plan was changed in 51 of 237 participants (22%) compared with the PET/CT-blinded surgical plan. In 34 participants (14%), this led to planned dissection of additional nodal levels. In 12 participants (5%), this led to fewer planned dissected nodal levels. Negative PET/CT scans in N0 necks was true negative in 87% and false negative in 13%.

CONCLUSION

[¹⁸F]fluorodeoxyglucose-PET/CT has high NPV for the N0 neck in T2 to T4 HNSCC. The surgical treatment plans on the basis of PET/CT findings may be changed in approximately 22% of this group. These findings suggest that [¹⁸F]fluorodeoxyglucose-PET/CT may assist the clinician in deciding on the best therapy for the clinically N0 neck in HNSCC. Well-designed clinical trials should be performed to test the outcome of omitting neck dissection by using PET/CT.

Relationship of Vitamin D Deficiency and Intraoperative Parathyroid Hormone Elevation in Completion and Total Thyroidectomy

Objective

To quantify how frequently intraoperative parathyroid hormone levels increase during thyroid surgery and to explore a possible relationship between secondary hyperparathyroidism due to vitamin D deficiency and elevation in intraoperative parathyroid hormone.

Study Design

Case series with chart review.

Setting

Tertiary academic center.

Subjects and Methods

A total of 428 consecutive patients undergoing completion and total thyroidectomy by the senior author over a 7-year period were included for analysis. All patients had baseline and postexcision intraoperative parathyroid hormone levels as well as vitamin D levels from the same laboratory. Institute of Medicine criteria were employed for vitamin D stratification (>30, normal; 20-29.9, insufficient; <20, deficient) . Other data analyzed include sex, age, neck dissection status, and parathyroid autotransplantation.

Results

A total of 118 patients (27.6%) had an intraoperative parathyroid hormone elevation above baseline. Patients with vitamin D deficiency were significantly more likely to experience hormone elevation ( P = .04). When parathyroid hormone rose, it did so by a mean 32.1 pg/mL. Patients with vitamin D deficiency demonstrated significantly larger hormone increases ( P = .03).

Conclusion

Elevation in intraoperative parathyroid hormone levels above baseline after completion and total thyroidectomy occurs in over one-fourth of cases and is significantly associated with vitamin D deficiency. This study is the first to report this observation. We hypothesize that vitamin D deficiency in these patients may create a subclinical secondary hyperparathyroidism that leads to intraoperative parathyroid hormone elevation when the glands are manipulated. Additional studies will be needed to explore this physiologic mechanism and its clinical significance.