Predictors of recurrence after total thyroidectomy in 1,611 patients with papillary thyroid carcinoma: postoperative stimulated serum thyroglobulin and ATA initial and dynamic risk assessment

Objective

Despite a favorable prognosis, some patients with papillary thyroid carcinoma (PTC) develop recurrence. The objective of this study was to examine the impact of the combination of initial American Thyroid Association (ATA) risk stratification with serum level of postoperative stimulated thyroglobulin (s-Tg) in predicting recurrence in patients with PTC and compare the results with an assessment of response to initial therapy (dynamic risk stratification).

Subjects and methods

We retrospectively analyzed 1,611 patients who had undergone total thyroidectomy for PTC, followed in most cases (87.3%) by radioactive iodine (RAI) administration. Clinicopathological features and s-Tg levels obtained 3 months postoperatively were evaluated. The patients were stratified according to ATA risk categories. Nonstimulated thyroglobulin levels and imaging studies obtained during the first year of follow-up were used to restage the patients based on response to initial therapy.

Results

After a mean follow-up of 61.5 months (range 12-246 months), tumor recurrence was diagnosed in 99 (6.1%) patients. According to ATA risk, recurrence was identified in 2.3% of the low-risk, 9% of the intermediate-risk, and 25% of the high-risk patients (p < 0.001). Using a receiver operating characteristic curve approach, a postoperative s-Tg level of 10 ng/mL emerged as the ideal cutoff value, with positive and negative predictive values of 24% and 97.8%, respectively (p < 0.001). Patients with low to intermediate ATA risk with postoperative s-Tg levels < 10 ng/mL and excellent response to treatment had a very low recurrence rate (<0.8%). In contrast, higher recurrence rates were observed in intermediate-riskto high-risk patients with postoperative s-Tg > 10 ng/mL and indeterminate response (25%) and in those with incomplete response regardless of ATA category or postoperative s-Tg value (38.5-87.5%). Using proportion of variance explained (PVE), the predicted recurrence using the ATA initial risk assessment alone was 12.7% and increased to 29.9% when postoperative s-Tg was added to the logistic regression model and 49.1% with dynamic risk stratification.

Conclusion

The combination of ATA staging system and postoperative s-Tg can better predict the risk of PTC recurrence. Initial risk estimates can be refined based ondynamic risk assessment following response to therapy, thus providing a useful guide for follow-up recommendations.

Aesthetic Perceptions Regarding a Thyroidectomy Scar and Transvestibular Approach in Brazil

OBJECTIVE

We investigated motivation levels across the general Brazilian population and subgroups and their willingness to spend for surgery without a cervical scar.

METHODS

This random-sample survey was performed by a specialized third-party research institute. In this study, we created a hypothetical thyroidectomy scenario, and the transcervical and transoral endoscopic thyroidectomy vestibular approach (TOETVA) were used. The survey included sociocultural data and questions regarding participants' surgical preferences.

RESULTS

Data were obtained from 1250 participants; 42.4% were of the opinion that a cervical scar affects social or professional life. Young and childless women were most likely to be affected (p <0.001). All respondents accepted the transoral approach to avoid cervical scarring. However, 30.7% and 31.9% of respondents maintained their preference for TOETVA despite understanding the risks of a hypothetical increase in complications and unfavorable oncological outcomes and 98.6% were of the opinion that this approach was likely associated with greater postoperative pain. Only 16.2% were unwilling to spend for TOETVA. The variable that most affected patients' willingness to spend was a salary greater than 10 Brazilian minimum wages (odds ratio 9.797, 95% confidence interval, p <0.005). Upper class respondents were 10 times more likely to spend for TOETVA than lower class patients.

CONCLUSION

This study highlights patients' interest in TOETVA. Cervical scar perception is affected by concerned about appearance, particularly in certain societal subgroups. Our study population showed significant motivation to undergo TOETVA, which was emphasized by their acceptance of the complication rate, poor postoperative outcomes, greater postoperative pain, and willingness to spend on surgery with an invisible scar.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Overview of glottic laryngeal cancer treatment recommendation changes in the NCCN guidelines from 2011 to 2022

BACKGROUND

The treatment of glottic cancer remains challenging, especially with regard to morbidity reduction and larynx preservation rates. The National Comprehensive Cancer Network (NCCN) has published guidelines to aid decision-making about this treatment according to the tumor site, clinical stage, and patient medical status.

AIM

The present review was conducted to identify changes in the NCCN guidelines for glottic cancer treatment made between 2011 and 2022 and to describe the published evidence concerning glottic cancer treatment and oncological outcomes in the same time period.

METHODS AND RESULTS

Clinical practice guidelines for head and neck cancer published from 2011 up to 2022 were obtained from the NCCN website (www.NCCN.org). Data on glottic cancer treatment recommendations were extracted, and descriptive analysis was performed. In addition, a review of literature registered in the PubMed database was performed to obtain data on glottic cancer management protocols and treatment outcomes from randomized controlled trials, systematic reviews, and meta-analyses published from 2011 to 2022. In total, 24 NCCN guidelines and updates and 68 relevant studies included in the PubMed database were identified. The main guideline changes made pertained to surgical and systemic therapies, the consideration of adverse features, and new options for the treatment of metastatic disease at initial presentation. Early-stage glottic cancer received the most research attention, with transoral endoscopic laser surgery and radiotherapy assessed and compared as the main treatment modalities. Reported associations between treatment types and survival rates for this stage of glottic cancer appear to be similar, but functional outcomes can be highly compromised.

CONCLUSION

NCCN panel members provide updated recommendations based on currently accepted treatment approaches for glottic cancer, constantly reviewing new surgical and non-surgical techniques. The guidelines support decision-making about glottic cancer treatment that should be individualized and prioritize patients' quality of life, functionality, and preferences.

Identification of secondary predictive factors for acute hypocalcemia following thyroidectomy in patients with low postoperative parathyroid hormone levels without overt calcium deficiency: A cohort study

BACKGROUND

The transient acute hypocalcemia (HypoCa) is the most prevalent complication after total thyroidectomy, detected primarily by subnormal intact parathyroid hormone (iPTH) and calcium levels. However, the need for calcium supplementation is ambiguous in patients who exhibit low iPTH with normal calcium levels. The aim of this study was to evaluate complementary predictors of HypoCa in this scenario.

METHODS

A retrospective cohort study with of 1597 consecutive patients undergoing total thyroidectomy, with or without neck dissection, from January 2014 to December 2018 at a single institution. Patients with an iPTH <12 pg/mL and a total calcium level ≥8 mg/dL in the first 8 h after surgery were included.

RESULTS

1597 patients identified with low postoperative iPTH without overt calcium deficiency was diagnosed. The transient HypoCa in that specific subgroup was 509 (31.9%). Multivariate analysis indicated that HYPOCA was associated with bilateral level VI neck dissection and pre- to postoperative calcium reduction >38 pg/mL. To better illustrate the model, we plotted a nomogram with the variables selected for the final model.

CONCLUSION

Total thyroidectomy patients who exhibit low postoperative iPTH levels without overt calcium deficiency should be considered for calcium replacement therapy when they a marked drop in iPTH postoperatively and underwent bilateral level VI neck dissection.

Organ preservation and oncological outcomes in early laryngeal cancer: a propensity score-based study

Background

The rates of laryngeal preservation according to therapeutic modality in patients with initial laryngeal squamous cell carcinoma (LSCC) are still controversial. This study evaluated the rates of laryngeal preservation in patients who underwent treatment with surgery or radiotherapy.

Methods

This retrospective cohort study evaluated 151 patients with stage I or II LSCC. Ninety-six patients were matched using a propensity-score and outcomes were compared within this group.

Results

Regarding overall, cancer-specific survival and larynx preservation, no differences were observed according to the therapeutic modalities, but patients who underwent radiotherapy had a higher rate of local recurrence than those who underwent surgery. Patients classified as ASA 3 or 4 and treated with radiotherapy showed a tendency of higher risk of larynx loss.

Conclusions

Patients with stage I or II laryngeal tumours can be submitted to surgery or radiotherapy with similar rates of laryngeal preservation.

Predictive factors for recurrence of papillary thyroid carcinoma: analysis of 4,085 patients

Objective

The incidence of papillary thyroid carcinoma (PTC) has increased in recent years and its treatment remains controversial. The objective of this study is to identify clinicopathological predictive factors of tumour recurrence.

Methods

We retrospectively analysed 4,085 patients who underwent thyroidectomy for PTC from 1996 to 2015. Patients were stratified according to American Thyroid Association (ATA) risk categories and clinicopathological features were evaluated to identify independent factors for recurrence.

Results

After a mean follow-up of 58.7 (range 3-256.5) months, tumour recurrence was diagnosed in 176 (4.3%) patients, mostly in lymph nodes. Distant metastasis occurred in 18 patients (0.4%). There were 3 (0.1%) cancer-related deaths. Multivariate analysis showed that tumour size >10 mm, multifocality, extrathyroidal extension and lymph node metastasis (all, P < 0.001) were independent risk factors for recurrence. Further, recurrence was identified in 1.6% of the ATA low-risk, 7.4% of the intermediate-risk and 22.7% of the high-risk patients (P < 0.001).

Conclusions

In PTC patients, tumour size >10 mm, multifocality, extrathyroidal extension and presence of lymph node metastasis as well as the ATA recurrence staging system effectively predict recurrence.

Risk Factors and Outcomes of Postoperative Neck Hematomas: An Analysis of 5,900 Thyroidectomies Performed at a Cancer Center

Introduction  Postoperative neck hematoma (PNH) is an uncommon but potentially-lethal complication of thyroid surgery.

Objective  To identify the risk factors for postthyroidectomy hematoma requiring reoperation, the timing, the source of the bleeding, the related respiratory distress requiring tracheotomy, and the late outcomes.

Methods  We retrospectively analyzed the records of 5,900 consecutive patients submitted to surgery for thyroid diseases at a single institution.

Results  In total, PNH occurred in 62 (1.1%) patients. Most cases of bleeding occurred within the first 6 hours after thyroidectomy, but 12.5% of the hematomas were observed after 24 hours. Obvious bleeding points were detected in 58.1% of the patients during the reoperation, with inferior thyroid artery branches and superior thyroid vessels being the most frequent bleeding sources. Only two patients required urgent tracheostomy. There were no hematoma-related deaths. Permanent hypoparathyroidism and recurrent laryngeal nerve injury are more frequent following reoperation for PNH. The factors significantly associated with PNH were: older age, concurrent lymph node dissection, and chronic lymphocytic thyroiditis. Gender, previous neck irradiation, presentation at diagnosis (symptomatic or incidental), substernal goiter, thyroidectomy for hyperthyroidism, prior thyroid surgery, malignant histology, the extent of the surgery (total versus non-total thyroidectomy), the use of energy-based vessel sealing devices, the use of the hemostatic agent Surgicel, and the placement of a surgical drain were not significantly associated with PNH.

Conclusion  Hematoma after thyroid surgery is an uncommon complication, but it is related to significant postoperative morbidity. A better understanding of the risk factors and of the time until hematoma formation can help target high-risk patients for preventive measures and closer postoperative observation.

Survival results of 3786 patients with stage I or II laryngeal squamous cell carcinoma: a study based on a propensity score

Introduction

Laryngeal squamous cell carcinoma is the second most prevalent malignancy among head and neck tumors, and the treatment of patients with stage I or II disease can be performed with surgery or radiation therapy. National population studies describing therapeutic results comparing these modalities are unusual, but they can be very important to direct treatment guidelines.

Objective

To evaluate the survival results of patients with laryngeal squamous cell carcinoma at clinical stages I or II, according to the main therapeutic modalities used.

Methods

Cross-sectional, population-based study using the database of Fundação Oncocentro de São Paulo from January 2000 to March 2019. Inclusion criteria were patients with laryngeal squamous cell carcinoma in clinical stages cT1-2N0. To compensate for the non-random allocation of patients and the imbalance between confounding variables between groups, we used the propensity score methodology.

Results

A total of 3786 patients met the inclusion criteria. Regarding the cT stage, there were 2171 patients (57.3%) with cT1 tumors. Patients in the public health system had a longer time between diagnosis and treatment (p < 0.001). The analysis by propensity score showed that patients treated with surgery had a tendency towards better disease-specific survival (p  = 0.012). Comparing radiotherapy alone versus its combination with radiochemotherapy, radiotherapy alone showed a tendency towards a better survival rate (p < 0.001).

Conclusion

Analysis by propensity score identified better results for disease-specific survival in patients with laryngeal squamous cell carcinoma at clinical stages I and II treated by surgery when compared to radiotherapy.

Preoperative vitamin D deficiency is a risk factor for postoperative hypocalcemia in patients undergoing total thyroidectomy: retrospective cohort study

BACKGROUND

The relationship between preoperative vitamin D deficiency and postoperative hypocalcemia in cases of total thyroidectomy (TT) is a matter of controversy and may vary according to geographical scenarios and populations.

OBJECTIVE

The objective here was to evaluate whether preoperative vitamin D deficiency was associated with postoperative symptomatic hypocalcemia in a population in South America.

DESIGN AND SETTING

Retrospective cohort study on data from all patients undergoing total thyroidectomy, with or without central compartment lymph node dissection, from January 2014 to December 2017, at the A. C. Camargo Cancer Center.

METHODS

Patients with benign thyroid disease (Graves' disease, multinodular goiter or hyperthyroidism) or thyroid cancer who underwent primary total thyroidectomy with or without central compartment lymph node dissection were included. The exclusion criteria were simultaneous parathyroidectomy and conditions that could affect serum calcium levels. The data collected included patient demographics, thyroid pathology, extent of the surgical procedure and complications. Information on preoperative and postoperative calcium, parathyroid hormone (PTH) and vitamin D levels were retrieved from the medical records.

RESULTS

1,347 patients were assessed and postoperative hypocalcemia was diagnosed in 284 patients (21%). The vitamin D levels were considered deficient in 243 patients (18%). Postoperative hypocalcemia was diagnosed in 357 patients (31.5%). Multivariate analysis showed that central compartment dissection and preoperative total calcium and deficient vitamin D levels were significant risk factors for postoperative hypocalcemia.

CONCLUSION

Deficient preoperative vitamin D levels were a significant risk factor for postoperative hypocalcemia. Preoperative oral supplementation should be considered, to minimize this risk.

Impact of systemic treatment associated to radiotherapy on quality of life in locally advanced head and neck cancer patients in Brazil: Prospective real-world data study

e17563

Background: the purpose of this study was to compare quality of life (QoL) and overall survival (OS) in patients with locally advanced head and neck cancer treated with radiotherapy only (RT), chemoradiotherapy with cisplatin (CT-RT) or RT with cetuximab (CET-RT). Methods: in this real-world, multi-institutional and prospective study, QoL outcomes were assessed using EORTC QLQ-C30 and QLQ-H&N43 questionnaires. Patients were treated according to each participating institution’s protocol. The Item Response Theory was used to generate a global QoL score, based on the 71 questions of both forms. Questionnaires were completed before treatment and every three months, thereafter. Survival was calculated using the Kaplan-Meyer method, and groups were compared by the log-rank test. The impact of the treatment modalities on QoL was analyzed using multivariate regression analyses. Results: Six hundred and twenty-six patients, with tumors located at the oral cavity (36%), oropharynx (30%), larynx (21%), hypopharynx (9%) and nasopharynx (4%) were included. Median follow up was 10.2 months. RT was delivered to 39% of the patients while 58% received CT-RT and 3% received CET-RT. Patients submitted to surgery were not included. OS was higher when systemic treatment was added to RT (median OS CET-RT: 21.9 months and CT-RT: 24.3 months, versus 14.2 months with RT, p < 0.05). A decrease in QoL during treatment was observed in all patients’ groups, but CT-RT had a statistically significant negative impact on QoL when compared to CET-RT (p = 0.02). An important limitation of the study is the low number of patients that received this last treatment modality, what is, probably, a result of local policies on reimbursement. Other factors that influenced QoL were alcohol consumption (better QoL for patients with no history of chronic alcohol consumption, p = 0.007) and radiotherapy technique (better QoL for patients treated with intensity-modulated RT, when compared to conformal RT, p < 0.001). Conclusions: We observed, as expected, better OS with systemic therapy, when associated to RT. A decrease in QoL was detected, as well, during treatment, but a less pronounced decrease was seen in patients receiving CET-RT, when compared to CT-RT. More studies are needed to confirm the QoL improvement in patients submitted to this last treatment approach.

Who are the low-risk patients that could benefit from watch-and-wait regarding the neck?

CONTEXT AND OBJECTIVE

The management of clinically negative neck is controversial, with an ongoing debate on the indication criteria and prognostic impact of different types of therapy. The aim here was to compare the results from neck dissection and watch-and-wait, among oral cancer patients who, clinically, did not show any evidence of neck metastasis.

DESIGN AND SETTING

Retrospective analysis in a tertiary cancer center hospital.

METHODS

Patients with epidermoid oral carcinoma were assessed. The inclusion criteria were: primary tumor restricted to the oral/oropharyngeal cavity, no previous treatment, surgical treatment as the first option, clinical/radiological stage N0 and no distant metastasis.

RESULTS

Two hundred and sixty-two patients were analyzed. The length of follow-up ranged from four to 369.6 months and, at the end, 118 patients were alive, 53 had died due to cancer, 84 had died from other causes and 7 had died after the operation. Among the patients who underwent neck dissection, lymphatic vascular embolization (P = 0.009) and tumor thickness (P = 0.002) were significant for regional recurrence, while for the watch-and-wait group, only tumor thickness was significant (P = 0.018). Through recursive partitioning, the patients without adverse prognostic factors and tumor thickness < 2 mm presented compatible results in the two groups.

CONCLUSION

Elective neck dissection seems to be the best treatment option. Patients who are eligible for watch-and-wait constitute a small group that, ideally, is categorized according to the postoperative pathological findings.

Impacto do esvaziamento cervical radical modificado no número de linfonodos recuperados, recorrência e sobrevida

Neck dissection is an integral part of head and neck tumors. Throughout its history, it has undergone changes looking for an improvement in functional outcome without loss of oncologic efficiency.

A new method for toilet training developmentally disabled children

20 profoundly retarded children (4 to 12 yr.) were trained, using a variety of relaxation and tension activities designed to help them differentiate and gain control of the toileting musculature. Operant techniques were used to reinforce appropriate urination. The post-training scores of the experimental and control groups differed significantly for both accidental and appropriate urination.