Drawing as a Way of Knowing: How a Mapping Model Assists Preoperative Evaluation of Patients with Thyroid Carcinoma

Background: Effective pre-surgical planning is crucial for achieving successful outcomes in endocrine surgery: it is essential to provide patients with a personalized plan to minimize operative and postoperative risks. Methods: Preoperative lymph node (LN) mapping is a structured high-resolution ultrasonography examination performed in the presence of two endocrinologists and the operating surgeon before intervention to produce a reliable "anatomical guide". Our aim was to propose a preoperative complete model that is non-invasive, avoids overdiagnosis of thyroid microcarcinomas, and reduces medical expenses. Results: The use of 'preoperative echography mapping' has been shown to be successful, particularly in patients with suspected or confirmed neoplastic malignancy. Regarding prognosis, positive outcomes have been observed both post-surgery and in terms of recurrence rates. We collected data on parameters such as biological sex, age, BMI, and results from cytologic tests performed with needle aspiration, and examined whether these parameters predict tumor malignancy or aggressiveness, calculated using a multivariate analysis (MVA). Conclusions: A standard multidisciplinary approach for evaluating neck lymph nodes pre-operation has proven to be an improved diagnostic and preoperative tool.

Distraction Gap Needed for Safe Central Compartment Access in Hip Arthroscopy

BACKGROUND

Sufficient distraction of the hip is the key to a safe central compartment (CC) approach in hip arthroscopy. However, an adequate distraction gap has not been scientifically identified.

PURPOSE

To determine the sufficient amount of distraction that could predict a successful CC access as well as to identify the risk factors for a failed or difficult CC access.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

All patients who underwent hip arthroscopy by a single surgeon between January 2018 and April 2019 were prospectively enrolled. We analyzed gaps of the hip on 4 C-arm fluoroscopic images: nondistraction, preoperative manual traction, preoperative maximal traction (without distension), and intraoperative maximal traction (at the end of CC procedures in a successful CC approach or after peripheral compartment procedures in a failed or difficult CC approach). A failed CC approach was defined as failure in introducing the anterolateral portal to the CC under arthroscopic control; a difficult CC approach was defined as the presence of an incomplete diagnostic round in the CC because of a small distraction. The amount of distraction was evaluated by the ratio of the distracted gap to the undistracted gap. Patients were classified into the successful CC access group (group 1) and the failed/difficult CC access group (group 2). The amount of distraction, demographic characteristics, and preoperative radiographic parameters were compared between the groups.

RESULTS

A total of 240 patients were included in this study. Group 1 consisted of 205 patients (113 males and 92 females; mean ± SD age, 34.5 ± 11.4 years), and group 2 consisted of 35 patients (27 males and 8 females; age, 32.5 ± 11.2 years). The preoperative joint space width was not significantly different between group 1 (mean ± SD, 3.89 ± 0.83 mm) and group 2 (3.68 ± 0.68 mm). The ratio of the amount of distraction at lateral gaps under all traction conditions was significantly greater in group 1 compared with group 2 (1.50 ± 0.54 vs 1.26 ± 0.35, respectively, under preoperative manual traction; 2.84 ± 0.76 vs 2.03 ± 0.63 under preoperative maximal traction; 3.36 ± 0.96 vs 2.50 ± 0.79 under intraoperative maximal traction). An increase of the lateral gap by >2.2 times (P < .001) under preoperative maximal traction and by >2.7 times (P < .001) under intraoperative maximal traction could predict successful CC access. Male sex (odds ratio [OR], 2.94; P = .017) and increased lateral center-edge angle (OR, 1.08 for every 1° increase; P = .004) were significant risk factors for failed/difficult CC access.

CONCLUSIONS

An increase of the lateral gap by >2.2 times during an unsterile traction test without joint distension could predict successful CC access. Male sex and increased lateral center-edge angle were risk factors for a failed or difficult CC access.

CCAD or eCRS: Defining Eosinophilic Subpopulations in Chronic Rhinosinusitis

BACKGROUND

Central compartment atopic disease (CCAD) and eosinophilic chronic rhinosinusitis (eCRS) are two clinical phenotypes of primary diffuse type 2 chronic rhinosinusitis (CRS) defined in the European Position Paper on Rhinosinusitis 2020 classification. Currently, the distinction between these subtypes relies on phenotypic features alone.

OBJECTIVE

This study aimed to investigate whether eosinophil activation differed between CCAD and eCRS.

METHODS

A cross-sectional study was conducted of adult patients presenting with CCAD and eCRS who had undergone functional endoscopic sinus surgery. Routine pathology results were obtained from clinical records. Eosinophils were counted on haematoxylin and eosin-stained formalin-fixed paraffin-embedded sinonasal tissue. Eotaxin-3, eosinophil peroxidase and immunoglobulin E levels were assessed using immunohistochemistry.

RESULTS

38 participants were included (51.7 ± 15.6 years, 47.4% female), of whom 36.8% were diagnosed with CCAD and 63.2% with eCRS. The eCRS group was characterised by older age (55.8 ± 16.3 vs 44.5 ± 11.8 years, p = 0.029), and on histology exhibited a higher degree of tissue inflammation (τ_b = 0.409, p = 0.011), greater proportion of patients with >100 eosinophils/high power field (87.5% vs 50%, p = 0.011), and higher absolute tissue eosinophil count (2141 ± 1947 vs 746 ± 519 cells/mm², p = 0.013). Eotaxin-3 scores were higher in the eCRS group (5.00[5.00-6.00] vs 6.00[6.00-6.75], p = 0.015). Other outcomes were similar.

CONCLUSIONS

Eosinophil and eotaxin-3 levels were elevated in eCRS compared with CCAD, suggesting a greater degree of eosinophil stimulation and chemotaxis. Patients with CCAD were younger. Future investigation and biomarkers may better distinguish CRS subpopulations.

Predictors of Central Compartment Involvement in Patients with Positive Lateral Cervical Lymph Nodes According to Clinical and/or Ultrasound Evaluation

Lymph node neck metastases are frequent in papillary thyroid carcinoma (PTC). Current guidelines state, on a weak level of evidence, that level VI dissection is mandatory in the presence of latero-cervical metastases. The aim of our study is to evaluate predictive factors for the absence of level VI involvement despite the presence of metastases to the lateral cervical stations in PTC. Eighty-eight patients operated for PTC with level II–V metastases were retrospectively enrolled in the study. Demographics, thyroid function, autoimmunity, nodule size and site, cancer variant, multifocality, Bethesda and EU-TIRADS, number of central and lateral lymph nodes removed, number of positive lymph nodes and outcome were recorded. At univariate analysis, PTC location and number of positive lateral lymph nodes were risk criteria for failure to cure. ROC curves demonstrated the association of the number of positive lateral lymph nodes and failure to cure. On multivariate analysis, the protective factors were PTC located in lobe center and number of positive lateral lymph nodes < 4. Kaplan–Meier curves confirmed the absence of central lymph nodes as a positive prognostic factor. In the selected cases, Central Neck Dissection (CND) could be avoided even in the presence of positive Lateralcervical Lymph Nodes (LLN+).

Impact of high-quality ultrasound following community ultrasound on surgical planning and active surveillance in patients with thyroid cancer

OBJECTIVE

Ultrasound (US) has gained a critical role in thyroid cancer treatment planning, yet it is limited by its user-dependent nature. The aim of this study was to compare the impact of US performed by radiologists specializing in thyroid imaging (hqUS) and US performed by radiographers in the community (cUS) on treatment plans of patients diagnosed with well-differentiated thyroid malignancies.

DESIGN

Retrospective single-centre case series with chart review.

PATIENTS

Patients diagnosed with thyroid cancer during 2017-2019 that had cUS followed by hqUS pre-operative counselling were included in this retrospective analysis.

MEASUREMENTS

The main outcome was management alternations based on one of two sonographic measures: (1) extrathyroid extension (ETE); (2) The presence of central or lateral lymph nodes suspicious for metastases (LNM), which were compared with the final pathology.

RESULTS

Among those with non-recurrent tumour (n = 76), ETE was reported 22 times more by hqUS compared with cUS (28.9% vs 1.3%, P < .001). Central and lateral LNM were reported approximately 6.5 and 1.5 times more by hqUS, respectively (25.0% vs 3.9%, P < .001 and 15.8% vs., 9.2%, P = .227, respectively). Overall, hqUS altered the initial treatment plan of 35.5% of patients. In 27.6% of patients, hqUS and its subsequent surgery resulted in a change to the patients' 2015 ATA risk stratification system. In 40% of patients with microcarcinomas, hqUS findings mandated surgery according to findings that were not reported by cUS. False-positive rate was 5.2%.

CONCLUSIONS

Community US may under-diagnose important features such as ETE and LNM, leading to potential under-treatment in many patients. High-quality US of the neck should be considered in patients with differentiated thyroid carcinoma before making any treatment decisions.

Indications and extent of central neck dissection for papillary thyroid cancer: An American Head and Neck Society Consensus Statement

BACKGROUND

The primary purposes of this interdisciplinary consensus statement were to review the relevant indications for central neck dissection (CND) in patients with papillary thyroid cancer (PTC) and to outline the appropriate extent and relevant techniques required to accomplish a safe and effective CND.

METHODS

A writing group convened by the American Head and Neck Society (AHNS) Endocrine Committee was tasked with identifying the important clinical elements to consider when managing the central neck compartment in patients with PTC based on available evidence in the literature, and the group's collective experience. The position statement paper was then submitted to the full Endocrine Committee, Education Committee, and AHNS Council.

RESULTS

This consensus statement was developed to inform the clinical decision-making process when managing the central neck compartment in patients with PTC from the AHNS. This document is intended to provide clarity through definitions as well as a basic guideline from which to manage the central neck. It is our hope that this improves the quality and reduces variation in management of the central neck, facilitates communication, and furthers research for patients with thyroid cancer.

CONCLUSION

This represents, in our opinion, contemporary optimal surgical care for this patient population and is endorsed by the American Head and Neck Society. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1269-1279, 2017.

Role of RAI in the management of incidental N1a disease in papillary thyroid cancer

BACKGROUND

Following total thyroidectomy (TT) for papillary thyroid cancer (PTC), pathological assessment can occasionally reveal incidental perithyroidal lymph nodes (LNs) with occult metastases. These cN0pN1a patients often receive radioactive iodine (RAI) therapy for this indication alone. The aim of this study was to determine the central compartment nodal recurrence-free survival in patients treated without RAI compared to those who received RAI treatment.

METHODS

An institutional database of 3664 previously untreated patients with differentiated thyroid cancer operated between 1986 and 2010 was reviewed. A total of 232 pT1-3 patients managed with TT and no neck dissection were subsequently found to have incidental level 6 LNs on pathology. Patients with other indications for RAI, such as extrathyroidal extension and close or positive margins, were excluded. One hundred and four patients remained for analysis. Kaplan-Meier method was used to determine central neck LN recurrence-free survival (RFS).

RESULTS

The median age of the cohort was 40 years (range 17-83). The median follow-up was 53 months (range 1-211). The median number of positive LNs removed and maximum LN diameter were 1 (range 1-8) and 5 mm (range 1-16 mm), respectively. A total of 67 (64%) patients had adjuvant RAI and 37 (36%) did not. Patients with vascular invasion (P = 0·01), LNs >2 mm (P = 0·07) and >2 positive nodes (P = 0·06) were more likely to be selected for adjuvant RAI therapy. Patients without RAI therapy had similar 5-year central neck LN RFS compared to those treated with RAI: 96·2% vs 94·6%, respectively (P = 0·92).

CONCLUSION

There is no difference in the 5-year central compartment nodal recurrence-free survival in patients treated without RAI compared to those who received RAI treatment.

Completion lobectomy and central compartment dissection in low-risk patients who had undergone less extensive surgery than hemithyroidectomy

Many low-risk patients with solitary papillary thyroid cancer located in one lobe had undergone surgery that was less extensive than hemithyroidectomy in China. An acceptable completion surgery regimen was suggested for these patients based on our experience. A total of 117 enrolled patients underwent completion surgery. Thirty-two patients had prior tumor resection, 46 patients had prior partial thyroidectomy and 39 patients had prior subtotal thyroidectomy. No neck dissection was performed. Reoperation was scheduled a median of 1.2 months (range, 3 days–6.5 months) after primary surgery for papillary thyroid cancer (PTC). Among the 117 patients, residual tumor was pathologically confirmed in 60 patients, with a residual rate of 51.28%. Among these 60 patients, residual tumor was identified in the thyroid bed alone in 18 patients and in compartment VI alone in 28 patients, while 14 patients exhibited residual tumor in both of these regions. Lymph node metastasis was observed in compartment VI in 42 patients (35.90%), and an average of 6.5 nodes were removed (range, 2–14 nodes for each patient). Additionally, 3.14 positive lymph nodes were removed on average from each of the 42 patients. We conclude that the completion regimen, including the ipsilateral residual lobe, the isthmus and ipsilateral compartment VI (prelaryngeal, pretracheal and paratracheal lymph nodes), is reasonable and acceptable for low-risk patients undergoing surgery that is less extensive than hemithyroidectomy.