1
|
Fung MMH, Wong IYH, Chan FSY, Law TT, Chan KK, Wong CLY, Law SYK, Lang BHH. A Prospective Study Evaluating the Feasibility and Accuracy of Post-operative Laryngeal Ultrasonography (LUSG) in Assessment of Vocal Cord Function After Esophagectomy. World J Surg 2023; 47:2792-2799. [PMID: 37540267 DOI: 10.1007/s00268-023-07128-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Vocal cord paresis (VCP) is a serious complication after esophagectomy. Conventional diagnosis of VCP relies on flexible laryngoscopy (FL), which is invasive. Laryngeal ultrasonography (LUSG) is non-invasive and convenient. It has provided accurate VC evaluation after thyroidectomy but it is unclear if it is just as accurate following esophagectomy. This prospective study evaluated the feasibility and accuracy of LUSG in VC assessment on day-1 after esophagectomy. METHODS Consecutive patients from a tertiary teaching hospital who underwent elective esophagectomy were prospectively recruited. All received pre-operative FL, and post-operative LUSG and FL on Day-1, each performed by a blinded, independent assessor. The primary outcomes were feasibility and accuracy of LUSG in the diagnosis of VCP on Day-1 post-esophagectomy. The accuracy of voice assessment (VA) was analyzed. RESULTS Twenty-six patients were eligible for analysis. The median age was 70 years (66-73). Majority were male (84.6%). Twenty-five (96.2%) received three-phase esophagectomy. Twenty-four (96%) had same-stage anastomosis at the neck. Three (11.5%) developed temporary and one (3.8%) developed permanent unilateral VCP. Overall VC visualization rate by LUSG was 100%; sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy of LUSG were 75.0%, 100%, 100%, 98.0%, 98.1% respectively, and superior to VA. Combining LUSG with VA findings could pick up all VCPs i.e. improved sensitivity and NPV to 100%. CONCLUSION LUSG is a highly feasible, accurate and non-invasive method to evaluate VC function early after esophagectomy. Post-operative FL may be avoided in patients with both normal LUSG and voice.
Collapse
Affiliation(s)
- Matrix Man-Him Fung
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Ian Yu-Hong Wong
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Fion Siu-Yin Chan
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Tsz-Ting Law
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Kwan-Kit Chan
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Claudia Lai-Yin Wong
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Simon Ying-Kit Law
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
| |
Collapse
|
2
|
Sinclair CF, Baek JH, Hands KE, Hodak SP, Huber TC, Hussain I, Lang BHH, Noel JE, Papaleontiou M, Patel KN, Russ G, Russell J, Spiezia S, Kuo JH. General Principles for the Safe Performance, Training, and Adoption of Ablation Techniques for Benign Thyroid Nodules: An American Thyroid Association Statement. Thyroid 2023; 33:1150-1170. [PMID: 37642289 PMCID: PMC10611977 DOI: 10.1089/thy.2023.0281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background: The primary goal of this interdisciplinary consensus statement is to provide a framework for the safe adoption and implementation of ablation technologies for benign thyroid nodules. Summary: This consensus statement is organized around three key themes: (1) safety of ablation techniques and their implementation, (2) optimal skillset criteria for proceduralists performing ablative procedures, and (3) defining expectations of success for this treatment option given its unique risks and benefits. Ablation safety considerations in pre-procedural, peri-procedural, and post-procedural settings are discussed, including clinical factors related to patient selection and counseling, anesthetic and technical considerations to optimize patient safety, peri-procedural risk mitigation strategies, post-procedural complication management, and safe follow-up practices. Prior training, knowledge, and steps that should be considered by any physician who desires to incorporate thyroid nodule ablation into their practice are defined and discussed. Examples of successful clinical practice implementation models of this emerging technology are provided. Conclusions: Thyroid ablative procedures provide valid alternative treatment strategies to conventional surgical management for a subset of patients with symptomatic benign thyroid nodules. Careful patient and nodule selection are critical to the success of these procedures as is extensive pre-procedural patient counseling. Although these emerging technologies hold great promise, they are not without risk and require the development of a unique skillset and environment for optimal, safe performance and consistent outcomes.
Collapse
Affiliation(s)
- Catherine F. Sinclair
- Icahn School of Medicine, New York, New York, USA
- Department of Otolaryngology, Monash University, Melbourne, Australia
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | - Steven P. Hodak
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy C. Huber
- Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Iram Hussain
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Brian Hung-Hin Lang
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Julia E. Noel
- Department of Otolaryngology Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | - Kepal N. Patel
- Division of Endocrine Surgery, Department of Surgery, New York University Langone Health, Bethesda, Maryland, USA
| | - Gilles Russ
- Thyroid Diseases and Endocrine Tumors Department, Pitié-Salpêtrière Hospital, Paris, France
- Institute of Cancer IUC, Clinical Research Group Thyroid Tumors No. 16, Sorbonne University, Paris, France
| | - Jonathon Russell
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Stefano Spiezia
- Endocrine and Ultrasound Guided Surgery Operative Unit, Ospedale del Mare, ASLNA1Centro, Naples, Italy
| | - Jennifer H. Kuo
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, New York, USA
| |
Collapse
|
3
|
Fung MMH, Tam DS, Lui DTW, Lang BHH. Pre-operative Cinacalcet Administration Reduces Immediate Post-operative Hypocalcemia Following Total Parathyroidectomy in Severe Renal Hyperparathyroidism. World J Surg 2023:10.1007/s00268-023-07030-4. [PMID: 37140608 DOI: 10.1007/s00268-023-07030-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND In severe renal hyperparathyroidism (RHPT), whether administrating Cinacalcet before total parathyroidectomy can reduce post-operative hypocalcemia remains unclear. We compared post-operative calcium kinetics between those who took Cinacalcet before surgery (Group I) and those who did not (Group II). METHODS Patients with severe RHPT (defined by PTH ≥ 100 pmol/L) who underwent total parathyroidectomy between 2012 and 2022 were analyzed. Standardized peri-operative protocol of calcium and vitamin D supplementation was followed. Blood tests were performed twice daily in the immediate post-operative period. Severe hypocalcemia was defined as serum albumin-adjusted calcium < 2.00 mmol/L. RESULTS Among 159 patients who underwent parathyroidectomy, 82 patients were eligible for analysis (Group I, n = 27; Group II, n = 55). Demographics and PTH levels before Cinacalcet administration were comparable (Group I: 169 ± 49 pmol/L vs Group II: 154 ± 45, p = 0.209). Group I had significantly lower pre-operative PTH (77 ± 60 pmol/L vs 154 ± 45, p < 0.001), higher post-operative calcium (p < 0.05), and lower rate of severe hypocalcemia (33.3% vs 60.0%, p = 0.023). Longer duration of Cinacalcet use correlated with higher post-operative calcium levels (p < 0.05). Cinacalcet use for > 1 year resulted in fewer severe post-operative hypocalcemia than non-users (p = 0.022, OR 0.242, 95% CI 0.068-0.859). Higher pre-operative ALP independently correlated with severe post-operative hypocalcemia (OR 3.01, 95% CI 1.17-7.77, p = 0.022). CONCLUSION In severe RHPT, Cinacalcet led to significant drop in pre-operative PTH, higher post-operative calcium levels, and less frequent severe hypocalcemia. Longer duration of Cinacalcet use correlated with higher post-operative calcium levels, and the use of Cinacalcet for > 1 year reduced severe post-operative hypocalcemia.
Collapse
Affiliation(s)
- Matrix Man-Him Fung
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Dick-Sang Tam
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - David Tak-Wai Lui
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
| |
Collapse
|
4
|
Wang AYM, Lo WK, Cheung SCW, Tang TK, Yau YY, Lang BHH. Parathyroidectomy versus oral cinacalcet on cardiovascular parameters in peritoneal dialysis patients with advanced secondary hyperparathyroidism (PROCEED): A randomized trial. Nephrol Dial Transplant 2023:7069339. [PMID: 36869794 DOI: 10.1093/ndt/gfad043] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND This trial aimed to evaluate oral cinacalcet versus total parathyroidectomy with forearm autografting (PTx) on cardiovascular surrogate outcomes and health-related quality of life (HRQOL) measures in dialysis patients with advanced SHPT. DESIGN In this pilot prospective randomized trial conducted in two university-affiliated hospitals, 65 adult peritoneal dialysis patients with advanced SHPT were randomized to receive either oral cinacalcet or PTx. Primary endpoints were changes in left ventricular (LV) mass index by cardiac magnetic resonance imaging and coronary artery calcium scores (CACS) over 12 months. Secondary endpoints included changes in heart valves calcium scores, aortic stiffness, biochemical parameters of chronic kidney disease-mineral bone disease (CKD-MBD) and HRQOL measures over 12 months. RESULTS Changes in LV mass index, CACS, heart valves calcium score, aortic pulse wave velocity and HRQOL did not differ between-groups or within-groups, despite significant reductions in plasma calcium, phosphorus and intact parathyroid hormone in both groups. Cinacalcet-treated patients experienced more cardiovascular-related hospitalizations than those who underwent PTx (P = 0.008) but the difference became insignificant after adjusting for baseline difference in heart failure (P = 0.43). With the same monitoring frequency, cinacalcet-treated patients had fewer hospitalizations due to hypercalcemia (1.8%) than patients who underwent PTx (16.7%) (P = 0.005). No significant changes were observed in HRQOL measures in either group. CONCLUSIONS Both cinacalcet and PTx effectively improved various biochemical abnormalities of CKD-MBD and stabilized but did not reduce LV mass, coronary artery and heart valves calcification, arterial stiffness or improve patient-centered HRQOL measures in PD patients with advanced SHPT. Cinacalcet may be used in place of PTx for treating advanced SHPT. Long-term and powered studies are required to evaluate PTx versus cinacalcet on hard cardiovascular outcomes in dialysis patients.
Collapse
Affiliation(s)
- Angela Yee-Moon Wang
- University Department of Medicine, Queen Mary Hospital, The University of Hong Kong
| | - Wai Kei Lo
- Department of Medicine, Tung Wah Hospital, Hong Kong
| | | | - Tak-Ka Tang
- University Department of Medicine, Queen Mary Hospital, The University of Hong Kong
| | | | - Brian Hung-Hin Lang
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| |
Collapse
|
5
|
Fung MMH, Lang BHH. A prospective study comparing the midline and lateral trans-laryngeal ultrasonography approaches in vocal cord assessment before and after thyroid and neck surgeries. Am J Surg 2021; 223:676-680. [PMID: 34238589 DOI: 10.1016/j.amjsurg.2021.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 06/27/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION It is unclear if placing an ultrasound probe along each thyroid cartilage lamina (i.e. the lateral approach) can improve vocal cord (VC) visualization over in the midline (i.e. the midline approach) in trans-larygeal ultrasonography (TLUSG). This study compared VC visualization rates and diagnostic accuracy between the two approaches. METHODS Consecutive patients undergoing surgery had their VCs assessed by the two TLUSG approaches and flexible laryngoscopy within the same session. VC visualization rates and diagnostic accuracy of each approach were calculated and compared. RESULTS Ninety patients (or 180 VCs) were analyzed. The lateral approach had significantly better overall VC visualization rate than the midline approach (93.3% vs. 82.2%, p=<0.001), especially for males (75.0% vs. 33.3%, p = 0.002). Both approaches had comparable accuracy (100% vs. 99.4%). CONCLUSIONS The lateral approach should be preferred because of the significantly better VC visualization rate and comparable accuracy to the midline approach.
Collapse
Affiliation(s)
- Matrix Man Him Fung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Brian Hung-Hin Lang
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.
| |
Collapse
|
6
|
Wong CKH, Liu X, Lang BHH. Cost-effectiveness of fine-needle aspiration cytology (FNAC) and watchful observation for incidental thyroid nodules. J Endocrinol Invest 2020; 43:1645-1654. [PMID: 32307641 DOI: 10.1007/s40618-020-01254-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/09/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES A trial-based comparison of the use of resources, costs and health utility outcomes of fine-needle aspiration cytology (FNAC), and watchful observation for incidental small (< 2 cm) thyroid nodules was performed using data from the randomized controlled trial (RCT). METHODS Using data from 314 patients, healthcare-related use of resources, costs, health utility, and quality-adjusted life years (QALYs) were estimated at 12 months after first presentation of incidental thyroid nodule(s) on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for FNAC versus watchful management at 12 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data. RESULTS FNAC management was associated with greater use of healthcare resources and mean direct healthcare costs per patient (US$542.47 vs US$411.55). Lower mean 12-month QALYs per patient in FNAC was observed in comparison to watchful observation (0.752 versus 0.758). The probability that FNAC management was cost-effective compared with watchful management at a willingness-to-pay threshold of US50,000 per QALY gained was 26.5%. CONCLUSION Based on 12-month data from RCT, watchful observation appeared cost-saving compared to FNAC in patients with incidental thyroid nodules that have a low-suspicion sonographic pattern and measure between 1.0 and 2.0 cm from healthcare provider perspective. CLINICALTRIALS. GOV IDENTIFIER NCT02398721.
Collapse
Affiliation(s)
- C K H Wong
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - X Liu
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - B H H Lang
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| |
Collapse
|
7
|
Lang BHH, Fung MMH. Intraoperative parathyroid hormone (IOPTH) assay might be better than the second-generation assay in parathyroidectomy for primary hyperparathyroidism. Surgery 2020; 169:109-113. [PMID: 32402543 DOI: 10.1016/j.surg.2020.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/27/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND It is unclear whether the third-generation intraoperative parathyroid hormone assay can improve surgical outcomes over second-generation assay in primary hyperparathyroidism. We aimed to compare the rate of decrease and diagnostic accuracy between the two assays after parathyroid adenoma excision. METHODS Consecutive patients undergoing parathyroidectomy with intraoperative parathyroid hormone were analyzed. Blood was drawn before and 10 minutes and 20 minutes after excision of the adenoma. The same blood sample was run simultaneously in the second-generation assays (Elecsys PTH STAT) and third-generation assays (Elecsys 1-84 PTH). Biochemical cure meant >50% intraoperative parathyroid hormone decrease at 10 minutes. Cure meant normocalcemia 6 months after operation. RESULTS Relative to the second-generation assay, the value of the intraoperative parathyroid hormone level was less in the third-generation assay before excision (P < .001), at 10 minutes (P < .001), and at 20 minutes (P < .001). The intraoperative parathyroid hormone rate of decrease and the proportion of normalized post-excision intraoperative parathyroid hormone were greater in the third-generation assay (P < .001), but the prediction accuracy appeared similar between the 2 (91.5% vs 91.0%). Patients with worse renal function (estimated glomerular filtration rate <80mL/min/1.73m2) had a slower intraoperative parathyroid hormone decrease in the second-generation but not in the third-generation assay. CONCLUSION Despite comparable accuracy between the two generations of assay, the third-generation assay might be better than the second-generation assay because of the more rapid decrease in the intraoperative parathyroid hormone and a greater percentage of normalized intraoperative parathyroid hormone, regardless of baseline renal function.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, University of Hong Kong, Hong Kong SAR, China.
| | - Matrix Man Him Fung
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, Hong Kong SAR, China
| |
Collapse
|
8
|
Lang BHH, Woo YC, Chiu KWH. Two-year outcomes of single-session high-intensity focused ultrasound (HIFU) treatment in persistent or relapsed Graves' disease. Eur Radiol 2019; 29:6690-6698. [PMID: 31209622 DOI: 10.1007/s00330-019-06303-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/03/2019] [Accepted: 06/04/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the longer-term disease relapse of ultrasound (US)-guided high-intensity focused ultrasound (HIFU) ablation as a treatment for persistent/relapsed Graves' disease (GD). METHODS After ethics approval, consecutive patients with persistent or relapsed GD who underwent bilateral US-guided HIFU ablation from 2016 to 2017 were retrospectively analyzed. Altogether, 75 patients received HIFU ablation of the central portion of the right and left thyroid lobes with areas near the trachea-esophageal groove and common carotid artery un-ablated. They were followed for 24 months or longer. Baseline thyrotropin (TSH), free T4, anti-thyroid autoantibodies, and TSH receptor (TSHR) antibody were checked. Primary outcome was the 24-month relapse rate. Relapse referred to hyperthyroidism (free T4 (FT4) > 23 pmol/L) afterwards. Variables associated with relapse were analyzed by binary logistic regression. RESULTS The cohort comprised mostly females (84.0%) with a mean age of 42.05 ± 10.74 years. The 24-month relapse rate was 41.3% with 31 patients suffering a relapse. No patient suffered from hypothyroidism. Three patients (4.0%) suffered from temporary vocal cord palsy but these injuries recovered spontaneously after 2 months. In univariate analysis, higher daily dose of carbimazole (OR = 1.125, 95% CI = 1.023-1.237, p = 0.015) and higher baseline TSHR level (OR = 1.085, 95% CI = 1.022-1.152, p = 0.007) were significant factors for disease relapse. In the multivariate analysis, higher baseline TSHR level was a significant independent factor for disease relapse within 24 months (OR = 1.079, 95% CI = 1.014-1.148, p = 0.016). CONCLUSIONS US-guided HIFU of the thyroid gland was a safe and relatively efficacious treatment in the longer term for patients with persistent or relapsed GD. KEY POINTS • US-guided HIFU ablation is relatively efficacious in the longer term. • US-guided HIFU ablation of the thyroid is safe. • Higher TSHR level may lead to higher disease relapse after treatment.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Hong Kong SAR, China.
| | - Yu-Cho Woo
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | | |
Collapse
|
9
|
Abstract
Pancreatic neuroendocrine tumours (PNETs) are rare. They are generally accepted to be slow-growing and have an indolent course. These tumours can be non-functioning or functioning, consisting of a biochemically heterogeneous group of tumours including insulinomas, gastrinomas, carcinoids and glucagonomas. Although surgery remains the mainstay of treatment, controversy still exists especially for non-functioning tumours <2 cm in size. Whether these should be resected or undergo intensive surveillance remains unclear. The surgical approach depends on local expertise. Many studies have shown comparable short-term surgical outcome with laparoscopic pancreatic resection compared to open techniques, however data on long-term oncological outcome are still lacking. On the other hand, liver metastasis occurs in as high as 80% of PNET patients. Five-year survival rate is only 30% if left untreated compared to 60-80% if complete resection is achieved. Current evidence supports liver resection with an aim for symptomatic control and to improve survival in those with respectable disease and no extra-hepatic metastasis. Palliative debunking can be considered in those with intractable symptoms. This article reviews the current evidence on pancreatic resection for PNETs, in particular the role of laparoscopic resection and the management of liver metastasis.
Collapse
Affiliation(s)
- Kai Pun Wong
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Julian Shun Tsang
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| |
Collapse
|
10
|
Lang BHH, Woo YC, Wong IYH, Chiu KWH. Single-Session High-Intensity Focused Ultrasound Treatment for Persistent or Relapsed Graves Disease: Preliminary Experience in a Prospective Study. Radiology 2017; 285:1011-1022. [PMID: 28727542 DOI: 10.1148/radiol.2017162776] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose To evaluate the safety and efficacy of ultrasonography (US)-guided high-intensity focused ultrasound (HIFU) ablation as a treatment for medically refractory Graves disease (GD). Materials and Methods After ethics approval, a prospective trial (NCT02685514) was performed from November 2015 to February 2016. Thirty patients underwent ablation of the entire right and left thyroid lobes, with areas near the tracheal-esophageal groove and common carotid artery left unablated. Serum thyroid-stimulating hormone (TSH), free T4 (FT4), antithyroid autoantibodies, and TSH receptor (TSHR) antibody levels were evaluated afterward, and US color Doppler, US volumetry, and eye assessment were performed. The primary outcome was the 12-month relapse rate. Relapse referred to hyperthyroidism (FT4 > 23 pmol/L) afterward. Variables associated with relapse were analyzed by using binary logistic regression. Results The technical success rate was 96.7%. The cohort comprised entirely women, with a median age of 38.2 years (interquartile range, 29.5-49.0 years). After 12 months, eight patients (26.7%; 95% confidence interval [CI]: 14.19%, 44.95%) experienced relapse. One patient (3.3%; 95% CI: 0.59%, 16.67%) experienced vocal cord palsy, while two patients (6.7%; 95% CI: 1.85%, 21.33%) experienced Horner syndrome, but none of these conditions were permanent. No changes in gland volume, antithyroid autoantibody levels, and ophthalmic parameters were found at 12-month follow-up. Baseline TSHR was found to have decreased significantly at 6- and 12-month follow-up (P < .001 for both). TSHR antibody (odds ratio [OR] = 1.414; 95% CI: 1.018, 1.965; P = .039) and gland volume (OR = 0.557; 95% CI: 0.353, 0.880; P = .012) were associated with 12-month relapse, with higher antibody levels conferring a higher likelihood and smaller gland volumes conferring a lower likelihood. Conclusion US-guided HIFU of the thyroid may be a safe and efficacious treatment in patients with persistent or relapsed GD. However, further study is warranted before it can become mainstream for this indication. © RSNA, 2017 Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- From the Departments of Surgery (B.H.H.L.), Medicine (Y.C.W.), Ophthalmology (I.Y.H.W.), and Radiology (K.W.H.C.), The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China
| | - Yu-Cho Woo
- From the Departments of Surgery (B.H.H.L.), Medicine (Y.C.W.), Ophthalmology (I.Y.H.W.), and Radiology (K.W.H.C.), The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China
| | - Ian Yat-Hin Wong
- From the Departments of Surgery (B.H.H.L.), Medicine (Y.C.W.), Ophthalmology (I.Y.H.W.), and Radiology (K.W.H.C.), The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China
| | - Keith Wan-Hang Chiu
- From the Departments of Surgery (B.H.H.L.), Medicine (Y.C.W.), Ophthalmology (I.Y.H.W.), and Radiology (K.W.H.C.), The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong Special Administrative Region, China
| |
Collapse
|
11
|
Lang BHH, Wu ALH. High intensity focused ultrasound (HIFU) ablation of benign thyroid nodules - a systematic review. J Ther Ultrasound 2017; 5:11. [PMID: 28523127 PMCID: PMC5434558 DOI: 10.1186/s40349-017-0091-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 02/09/2017] [Indexed: 12/13/2022] Open
Abstract
Background With an increasing number of imaging studies being done nowadays, the number of incidentally discovered thyroid nodules is expected to rise. Although many of these nodules are small and benign in nature, some do grow and may cause pressure and/or thyrotoxic symptoms. Surgical resection has traditionally been recommended for symptomatic nodules but is associated with risk of hypothyroidism, bleeding, infection, and nerve damage. High intensity focused ultrasound (HIFU) is one of the non-surgical thermal ablation techniques that may serve as an alternative in the treatment of benign thyroid nodules. The present review is to systematically evaluate the efficacy and safety of HIFU ablation. Methods We comprehensively searched all studies that evaluated the use of HIFU ablation as a treatment of benign thyroid nodules from Medline (PubMed) and Cochrane Library electronic databases using specific keywords. All titles identified by the search strategy were independently screened by two authors. Case reports, animal studies, editorials, expert opinions, reviews without original data and studies on pediatric population were excluded. Multiple reports of the same dataset were assessed and the most representative and updated report of a study was included. Results Five original studies were found. All treated thyroid nodules were confirmed to be benign cytologically and either appeared solid or predominantly (>70%) solid on ultrasonography. Only one type of commercially available US-guided device with an extracorporeal probe (3 MHz) was used in all the reported treatments. No major complications including recurrent laryngeal nerve injury, skin burn or haematoma were reported in all of the studies. The overall nodule volume reduction after single session of HIFU ablation ranged between 45 and 68%, depending on nodule size and length of follow-up. Conclusions Despite the few number of studies, our review appeared to suggest that HIFU is a safe and efficacious method of treating symptomatic benign thyroid nodules. However, larger-scale, prospective trials with longer follow-up period are indeed required to confirm this. In terms of the ablation itself, relative to other ablation techniques, there are still much room for improvements in shortening treatment duration and expanding the range of treatable nodules.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR China.,Department of Surgery, Division of Endocrine Surgery, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, SAR China
| | - Arnold L H Wu
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR China
| |
Collapse
|
12
|
Abstract
BACKGROUND High-intensity focused ultrasound (HIFU) is a new promising thermal ablation technique for treating benign thyroid nodules, but its effectiveness in larger-sized nodules has been less well described. The present study aimed to evaluate the treatment efficacy (i.e., extent of shrinkage at six months) of large-sized benign thyroid nodules by ultrasound (USG)-guided HIFU ablation. MATERIALS AND METHODS After ethics approval, all consecutive patients who underwent HIFU ablation of a symptomatic benign thyroid nodule with six or more months of follow-up were analyzed. Treated nodules were categorized according to their pre-ablation volume (group I: <10 mL; groups II: 10-30 mL; group III: >30 mL). After treatment, the nodule volume was measured by USG at one week, one month, three months, and six months. Total energy delivered to each nodule (in kJ) and the time taken (in minutes) for that delivery were automatically recorded. The primary outcome was a change in nodule volume after six months, where percentage nodule volume change was calculated as (baseline volume - volume at six months)/(baseline volume) × 100. Ablation success was defined as >50% volume reduction. RESULTS Seventy-three nodules were treated successfully and followed for ≥6 months. The overall median six-month volume reduction was 68.3% (range 22.77-96.50%). At six months, group III had a significantly less volume shrinkage than group I (48.1% vs. 77.6%; p < 0.001) and group II (48.1% vs. 67.9%; p = 0.002). Also, the proportion of ablation success at six months in group III was significantly less than in the other two groups (p < 0.001). Pre-ablation nodule volume >30 mL (odds ratio = 7.813 [confidence interval 1.908-32.258]; p = 0.004) and lower total energy per nodule volume (odds ratio = 3.313 [confidence interval 1.113-9.688]; p = 0.029) were significant factors for less ablation success. CONCLUSIONS Single-session HIFU ablation was highly effective in causing shrinkage of benign thyroid nodules at six months, but the extent of shrinkage for larger-sized nodules (>30 mL) was noticeably less than that of smaller-sized nodules. Both pre-ablation nodule volume and total energy per nodule volume were significant determinants of ablation success. For larger-sized nodules, additional HIFU treatment three to six months after initial treatment might be preferred over sequential treatment within the same session.
Collapse
Affiliation(s)
| | - Yu-Cho Woo
- 2 Department of Medicine, The University of Hong Kong , Hong Kong SAR, China
| | - Keith Wan-Hang Chiu
- 3 Department of Radiology, The University of Hong Kong , Hong Kong SAR, China
| |
Collapse
|
13
|
Abstract
Purpose To evaluate first-year efficacy and changes in pressure symptoms and health-related quality of life (HRQOL) after ultrasonographically (US) guided high-intensity focused ultrasound (HIFU) ablation of symptomatic benign thyroid nodules. Materials and Methods After ethics approval and informed consent were obtained, a prospective trial was conducted. Patients with a symptomatic benign thyroid nodule were given a choice of HIFU treatment or active surveillance. Clinical and US examinations, pressure symptom scores (visual analog scale), and HRQOL questionnaires (short form-12 survey) were evaluated at baseline and at 3, 6, and 12 months. The primary outcome was change in nodule volume after 12 months. The percentage of change in nodule volume was defined as the baseline volume minus the volume at 12 months divided by the baseline volume times 100. Ablation success was defined as a reduction in volume of greater than 50%. Nodule volume was compared by using the paired t test. Continuous variables were compared by using the Mann-Whitney U test, and categorical variables were compared by using χ2 tests. Results Twenty-two patients underwent HIFU and 22 underwent active surveillance. Mean age was 53.11 years (range, 28-76 years) and 55.19 years (range, 41-70 years), respectively. The ratio of men to women was 2:20 and 1:21, respectively. The 12-month mean volume reduction ± standard deviation in the HIFU group was significant (68.87% ± 15.27 [range, 47.35%-94.89%], P < .001) but not in the surveillance group (-2.11% ± 6.29 [range, -15.64% to 12.70%], P > .05). Preablation nodule volume was the only determinant of ablation success (odds ratio, 1.877; 95% confidence interval [CI]: 1.085, 3.249; P = .024). At 12 months, patients in the HIFU group had less swelling (P < .001), lower pressure symptom scores (P < .001), and higher physical composite scores (P = .006). Physical composite scores significantly correlated with 6-month reduction in nodule size (r = 0.768; 95% CI: 0.660, 0.930; P < .001) and 12-month reduction in nodule size (r = 0.704; 95% CI: 0.680, 940; P < .001). Conclusion HIFU ablation of symptomatic benign thyroid nodules not only induced significant shrinkage but also improved pressure symptom scores and HRQOL throughout a 12-month period. © RSNA, 2017.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- From the Departments of Surgery (B.H.H.L.), Medicine (Y.C.W.), and Family Medicine and Primary Care (C.K.H.W.), The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Rd, Hong Kong SAR, China
| | - Yu-Cho Woo
- From the Departments of Surgery (B.H.H.L.), Medicine (Y.C.W.), and Family Medicine and Primary Care (C.K.H.W.), The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Rd, Hong Kong SAR, China
| | - Carlos K H Wong
- From the Departments of Surgery (B.H.H.L.), Medicine (Y.C.W.), and Family Medicine and Primary Care (C.K.H.W.), The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Rd, Hong Kong SAR, China
| |
Collapse
|
14
|
Lang BHH, Shek TWH, Wu ALH, Wan KY. The total number of tissue blocks per centimetre of tumor significantly correlated with the risk of distant metastasis in patients with minimally invasive follicular thyroid carcinoma. Endocrine 2017; 55:496-502. [PMID: 27928729 DOI: 10.1007/s12020-016-1188-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Given that careful histological examination plays a pivotal role in follicular thyroid carcinoma categorization, we hypothesize that the number of blocks taken at initial specimen review may be associated with survival outcomes of patients initially diagnosed with minimally invasive follicular thyroid carcinoma. METHODS A total of 162 patients with confirmed minimally invasive follicular thyroid carcinoma were analyzed. The number of tissue blocks taken from each patient was recorded and the number of blocks per each centimeter of tumor was calculated. A multivariate analysis was conducted to identify independent factors for distant metastasis-free survival. RESULTS After a mean follow-up of 197.88 ± 155.39 months, 7 (4.3%) patients developed distant metastasis during follow-up (group II). Relative to those who remained disease-free (group I), group II were significantly older at initial operation (p = 0.022), had larger tumors (p = 0.002) and fewer number of blocks taken/cm of tumor (p = 0.001). However, after adjusting for age at initial operation and tumor size, total number of tissue blocks taken/cm of tumor was the only independent determinant for distant metastasis-free survival (p = 0.049). The 10-year distant metastasis-free survival was significantly better in those who had ≥ 4 blocks/cm of tumor (n = 82) than those with ≤ 3 block/cm of tumor (n = 80) (100 vs. 84.7%, p = 0.005, by log rank). CONCLUSIONS Although our study was not able to identify the precise cause for the association between the total number of tissue blocks taken/cm of tumor and distant metastasis-free survival, our data support a more liberal approach in taking tissue blocks on thyroid nodules especially those showing well-differentiated follicular cell differentiation.
Collapse
Affiliation(s)
| | - Tony W H Shek
- Department of Anatomical Pathology, The University of Hong Kong, Hong Kong, SAR, China
| | - Arnold L H Wu
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR, China
| | - Koon Yat Wan
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong, SAR, China
| |
Collapse
|
15
|
Lang BHH, Wong CKH, Wong KP, Chu KKW, Shek TWH. Effect of Thyroid Remnant Volume on the Risk of Hypothyroidism After Hemithyroidectomy: A Prospective Study. Ann Surg Oncol 2017; 24:1525-1532. [PMID: 28058547 DOI: 10.1245/s10434-016-5743-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypothyroidism is a common sequel after a hemithyroidectomy. Although various risk factors leading to hypothyroidism have been reported, the effect of the contralateral lobe's volume has been understudied. This study aimed to examine the association between the preoperative contralateral lobe's volume and the risk of postoperative hypothyroidism. METHODS During a 2-year period, 150 eligible patients undergoing a hemithyroidectomy were evaluated. The volume of the contralateral nonexcised lobe was estimated preoperatively by independent assessors on ultrasonography using the following formula: width (in cm) × depth (in cm) × length (in cm) × (π/6), adjusted for the body surface area (BSA). Postoperative hypothyroidism was defined as serum thyroid-stimulating hormone (TSH) exceeding 4.78 mIU/L. Any significant characteristics in the univariate analysis were entered into the multivariate analysis to determine independent factors. RESULTS After a mean follow-up period of 53.5 ± 9.4 months, 44 patients (29.3 %) experienced postoperative hypothyroidism, and 10 of these patients required thyroxine replacement. Hypothyroidism was associated with a higher preoperative TSH level (p < 0.001), a smaller BSA-adjusted volume (p < 0.001), fewer ipsilateral nodules (p = 0.037), and the presence of thyroiditis (p = 0.050). After adjustment for thyroiditis, preoperative TSH (p < 0.001), number of ipsilateral nodules (p = 0.048), and BSA-adjusted volume (p < 0.001) were independent factors for hypothyroidism. Patients with a BSA-adjusted volume smaller than 3.2 ml had a threefold greater hypothyroidism risk than those with a BSA-adjusted volume of 3.2 ml or more (p < 0.001). CONCLUSIONS A significant inverse association between the preoperative contralateral lobe's volume and hypothyroidism risk was observed after hemithyroidectomy. Together with a higher preoperative TSH level and fewer ipsilateral nodules, a smaller BSA-adjusted volume measured by preoperative ultrasonography independently predicted hypothyroidism.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Department of Surgery, The University of Hong Kong, Hong Kong, China. .,Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China.
| | - Carlos K H Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
| | - Kai Pun Wong
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Kelvin Ka-Wan Chu
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Tony W H Shek
- Department of Anatomical Pathology, The University of Hong Kong, Hong Kong, China
| |
Collapse
|
16
|
Wong KP, Au KP, Lam S, Lang BHH. Lessons Learned After 1000 Cases of Transcutaneous Laryngeal Ultrasound (TLUSG) with Laryngoscopic Validation: Is There a Role of TLUSG in Patients Indicated for Laryngoscopic Examination Before Thyroidectomy? Thyroid 2017; 27:88-94. [PMID: 27762673 DOI: 10.1089/thy.2016.0407] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Patients with hoarseness of voice, previous neck operation, or suspicion of malignancy are at high risk of having pre-thyroidectomy vocal cord (VCP) palsy. Therefore, vocal cord (VC) functions should be evaluated before surgery. This study aimed to evaluate the accuracy of hoarseness, a voice-related questionnaire (Voice Handicap Index [VHI]-30), and transcutaneous laryngeal ultrasound (TLUSG) in diagnosing VCP, as well as the role of TLUSG in the evaluation of high-risk patients. METHODS A total of 1000 patients undergoing thyroidectomy or other endocrine-related neck procedures were prospectively included. Symptoms of hoarseness, the VHI-30 score, and TLUSG were evaluated. Validation laryngoscopies were performed by a separate endoscopist after performing TLUSG. All the assessments were performed one to seven days before surgery. The findings of hoarseness, the VHI-30 score, and TLUSG were correlated with laryngoscopic findings to evaluate the diagnostic accuracy. RESULTS Of 1000 patients, nine preoperative VCP were diagnosed with laryngoscopy. Sensitivity in detecting VCP by hoarseness, the VHI-30 score, and TLUSG were 33.3%, 62.5%, and 88.9%, respectively. A total of 342 patients were considered as high risk, and eight preoperative VCP were confirmed with laryngoscopy. Despite it not being possible to visualize the VCs in 26 (7.7%) patients, TLUSG had a higher accuracy in detecting VCP than the VHI-30 did (96.8% vs. 74.2%; p < 0.001). If patients had been selected who were unassessable or who had had VCP on assessment for confirmatory laryngoscopy, TLUSG saved more patients from laryngoscopic examinations than the VHI-30 did (87.7% vs. 71.3%; p < 0.001). A history of neck operation and suspicion of malignancy did not affect the assessment by TLUSG (p > 0.05). CONCLUSION TLUSG is a feasible, non-invasive, and sensitive tool in detecting VCP in high-risk patients. It has safely precluded 87.7% high-risk patients from laryngoscopy. TLUSG should be incorporated as a part of the ultrasound examination of the thyroid.
Collapse
Affiliation(s)
- Kai-Pun Wong
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong , Queen Mary Hospital, Hong Kong SAR, China
| | - Kin-Pan Au
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong , Queen Mary Hospital, Hong Kong SAR, China
| | - Shi Lam
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong , Queen Mary Hospital, Hong Kong SAR, China
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong , Queen Mary Hospital, Hong Kong SAR, China
| |
Collapse
|
17
|
Lang BHH, Shek TWH, Chan AOK, Lo CY, Wan KY. Significance of Size of Persistent/Recurrent Central Nodal Disease on Surgical Morbidity and Response to Therapy in Reoperative Neck Dissection for Papillary Thyroid Carcinoma. Thyroid 2017; 27:67-73. [PMID: 27750029 DOI: 10.1089/thy.2016.0337] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND To balance the risk of disease progression, morbidity, and efficacy of reoperative central neck dissection (RCND) in papillary thyroid carcinoma, the latest clinical guidelines recommend early surgery over surveillance when the largest diseased node is >8 mm in its smallest dimension. However, the evidence remains scarce. To determine an appropriate size for first-time RCND, the relationship between size of largest diseased central node, morbidity, and response-to-therapy following RCND was examined. METHODS A total of 130 patients who underwent RCND following initial surgery for persistent/recurrent nodal disease were reviewed. Patients with largest diseased central node measured preoperatively by ultrasonography were included. Eligible patients were categorized into three groups: largest central node <10 mm (group I), 10-15 mm (group II), and >15 mm (group III). Surgical morbidity and response to therapy at one year after RCND were compared between groups. To evaluate biochemical response, patients with structural incompleteness were excluded. RESULTS Group III not only had significantly more high-risk tumors (by American Thyroid Association risk stratification) at initial therapy (64.5% vs. 44.4%, respectively; p = 0.038), but this group also a higher risk of extranodal extension (35.5% vs. 16.0%; p = 0.055), recurrent laryngeal nerve involvement (19.4% vs. 0.0%; p < 0.001), incomplete surgical resection (48.4% vs. 7.4%; p < 0.001), new-onset vocal cord paresis (16.7% vs. 2.5%; p = 0.017), overall surgical morbidity (22.6% vs. 7.4%; p = 0.021), and biochemical incompleteness (80.6% vs. 67.9%; p = 0.004) than groups I and II combined did. However, overall morbidity did not differ between groups I and II (5.7% vs. 8.7%; p = 0.694). After adjusting for American Thyroid Association risk stratification, only the size of the largest diseased central node ≥15 mm (odds ratio = 7.256 [confidence interval 1.302-40.434], p = 0.001) was an independent risk factor for biochemical incompleteness following RCND. CONCLUSIONS Patients with larger diseased central node(s) had a significantly higher risk of local invasion, surgical morbidity, and biochemical incompleteness. Relative to nodal size <10 mm, size >15 mm in the largest disease central node was an independent risk factor for incomplete biochemical response, while nodal size 10-15 mm was not. These findings imply that the recommended threshold of 8 mm might be too stringent and could be raised to 15 mm without increasing the surgical morbidity from RCND.
Collapse
Affiliation(s)
| | - Tony W H Shek
- 2 Department of Anatomical Pathology, The University of Hong Kong , Hong Kong SAR, China
| | - Angel On-Kei Chan
- 3 Division of Clinical Biochemistry, Department of Pathology and Clinical Biochemistry, Queen Mary Hospital , Hong Kong SAR, China
| | - Chung-Yau Lo
- 1 Department of Surgery, The University of Hong Kong , Hong Kong SAR, China
| | - Koon Yat Wan
- 4 Department of Clinical Oncology, The University of Hong Kong , Hong Kong SAR, China
| |
Collapse
|
18
|
Lang BHH, Wong CKH, Hung HT, Wong KP, Mak KL, Au KB. Indocyanine green fluorescence angiography for quantitative evaluation of in situ parathyroid gland perfusion and function after total thyroidectomy. Surgery 2016; 161:87-95. [PMID: 27839936 DOI: 10.1016/j.surg.2016.03.037] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/25/2016] [Accepted: 03/28/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Because the fluorescent light intensity on an indocyanine green fluorescence angiography reflects the blood perfusion within a focused area, the fluorescent light intensity in the remaining in situ parathyroid glands may predict postoperative hypocalcemia risk after total thyroidectomy. METHODS Seventy patients underwent intraoperative indocyanine green fluorescence angiography after total thyroidectomy. Any parathyroid glands with a vascular pedicle was left in situ while any parathyroid glands without pedicle or inadvertently removed was autotransplanted. After total thyroidectomy, an intravenous 2.5 mg indocyanine green fluorescence angiography was given and real-time fluorescent images of the thyroid bed were recorded using the SPY imaging system (Novadaq, Ontario, Canada). The fluorescent light intensity of each indocyanine green fluorescence angiography as well as the average and greatest fluorescent light intensity in each patient were calculated. Postoperative hypocalcemia was defined as adjusted calcium <2.00 mmol/L within 24 hours. RESULTS The fluorescent light intensity between discolored and normal-looking indocyanine green fluorescence angiographies was similar (P = .479). No patients with a greatest fluorescent light intensity >150% developed postoperative hypocalcemia while 9 (81.8%) patients with a greatest fluorescent light intensity ≤150% did. Similarly, no patients with an average fluorescent light intensity >109% developed PH while 9 (30%) with an average fluorescent light intensity ≤109% did. The greatest fluorescent light intensity was more predictive than day-0 postoperative hypocalcemia (P = .027) and % PTH drop day-0 to 1 (P < .001). CONCLUSION Indocyanine green fluorescence angiography is a promising operative adjunct in determining residual parathyroid glands function and predicting postoperative hypocalcemia risk after total thyroidectomy.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Carlos K H Wong
- Department of Family Medicine and Primary Care, University of Hong Kong, 3/F Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong SAR, China
| | - Hing Tsun Hung
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kai Pun Wong
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ka Lun Mak
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kin Bun Au
- Division of Endocrine Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| |
Collapse
|
19
|
Lang BHH, Wong CKH. Lobectomy is a more Cost-Effective Option than Total Thyroidectomy for 1 to 4 cm Papillary Thyroid Carcinoma that do not Possess Clinically Recognizable High-Risk Features. Ann Surg Oncol 2016; 23:3641-3652. [DOI: 10.1245/s10434-016-5280-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Indexed: 11/18/2022]
|
20
|
Lang BHH, Shek TWH, Wan KY. Does microscopically involved margin increase disease recurrence after curative surgery in papillary thyroid carcinoma? J Surg Oncol 2016; 113:635-9. [PMID: 26843438 DOI: 10.1002/jso.24194] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 01/21/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND The prognostic significance of microscopically involved margin in papillary thyroid carcinoma (PTC) following curative surgery remains unclear. We aimed to evaluate the impact of an involved margin and its location (anterior vs. posterior) on disease recurrence. METHODS Of the 638 eligible patients, 538 (85.9%) did not have an involved margin (group I) while 100 (14.1%) did (group II). The latter group was further classified according to its location relative to the surface of the thyroid gland (anterior or posterior). A multivariate analysis was conducted to identify independent factors for recurrence risk. RESULTS After a mean of 130.1 ± 93.5 months, 22 patients had disease recurrence. The 10-year disease-free survival (DFS) was significantly worse in group II (95.0% vs. 97.0%, P = 0.011). After adjusting other significant factors, involved margin was not an independent risk factor for disease recurrence (P = 0.358). Compared to a negative margin, an anterior involved margin did not pose increased recurrence risk (HR = 1.21, 95%CI = 0.93-500.00, P = 0.368), whereas a posterior involved margin had almost 23 times higher recurrence risk (HR = 22.95; 95%CI = 4.33-121.70, P < 0.001). CONCLUSIONS Overall, a microscopically involved margin was not an independent factor for DFS. However, although an anterior involved margin itself did not increase disease recurrence, a posterior involved margin did. J. Surg. Oncol. 2016;113:635-639. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
| | - Tony W H Shek
- Department of Anatomical Pathology, The University of Hong Kong, Hong Kong SAR, China
| | - Koon Yat Wan
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong SAR, China
| |
Collapse
|
21
|
Lee CH, Cheung CYY, Chow WS, Woo YC, Yeung CY, Lang BHH, Fong CHY, Kwok KHM, Chen SPL, Mak CM, Tan KCB, Lam KSL. Genetics of Apparently Sporadic Pheochromocytoma and Paraganglioma in a Chinese Population. Horm Metab Res 2015; 47:833-8. [PMID: 26267327 DOI: 10.1055/s-0035-1555955] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Identification of germline mutation in patients with apparently sporadic pheochromocytomas and paragangliomas is crucial. Clinical indicators, which include young age, bilateral or multifocal, extra-adrenal, malignant, or recurrent tumors, predict the likelihood of harboring germline mutation in Caucasian subjects. However, data on the prevalence of germline mutation, as well as the applicability of these clinical indicators in Chinese, are lacking. We conducted a cross-sectional study at a single endocrine tertiary referral center in Hong Kong. Subjects with pheochromocytomas and paragangliomas were evaluated for the presence of germline mutations involving 10 susceptibility genes, which included NF1, RET, VHL, SDHA, SDHB, SDHC, SDHD, TMEM 127, MAX, and FH genes. Clinical indicators were assessed for their association with the presence of germline mutations. Germline mutations, 2 being novel, were found in 24.4% of the 41 Chinese subjects recruited and 11.4% among those with apparently sporadic presentation. The increasing number of the afore-mentioned clinical indicators significantly correlated with the likelihood of harboring germline mutation in one of the 10 susceptibility genes. (r=0.757, p=0.026). The presence of 2 or more clinical indicators should prompt genetic testing for germline mutations in Chinese subjects. In conclusion, our study confirmed that a significant proportion of Chinese subjects with apparently sporadic pheochromocytoma and paraganglioma harbored germline mutations and these clinical indicators identified from Caucasians series were also applicable in Chinese subjects. This information will be of clinical relevance in the design of appropriate genetic screening strategies in Chinese populations.
Collapse
Affiliation(s)
- C H Lee
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - C Y Y Cheung
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - W S Chow
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - Y C Woo
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - C Y Yeung
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - B H H Lang
- Department of Surgery, Queen Mary Hospital, Hong Kong SAR, China
| | - C H Y Fong
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - K H M Kwok
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - S P L Chen
- Kowloon West Cluster Laboratory Genetic Service, Department of Pathology, Princess Margaret Hospital, Hong Kong SAR, China
| | - C M Mak
- Kowloon West Cluster Laboratory Genetic Service, Department of Pathology, Princess Margaret Hospital, Hong Kong SAR, China
| | - K C B Tan
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - K S L Lam
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| |
Collapse
|
22
|
Lang BHH, Ng CPC, Au KB, Wong KP, Wong KKC, Wan KY. Does preoperative neutrophil lymphocyte ratio predict risk of recurrence and occult central nodal metastasis in papillary thyroid carcinoma? World J Surg 2015; 38:2605-12. [PMID: 24809487 DOI: 10.1007/s00268-014-2630-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Preoperative neutrophil to lymphocyte ratio (NLR) might be prognostic in papillary thyroid carcinoma (PTC). Given the controversy of prophylactic central neck dissection (pCND) in clinically nodal-negative (cN0) PTC, our study evaluated whether preoperative NLR predicted disease-free survival (DFS) and occult central nodal metastasis (CNM) in cN0 PTC. METHODS A total of 191 patients who underwent pCND were analyzed. Complete blood counts with differential counts were taken before operation. NLR was calculated by dividing preoperative neutrophil count with lymphocyte count. Patients were categorized into NLR tertiles: first (NLR < 1.93; n = 63), second (NLR = 1.93-2.79; n = 64), and third tertile (NLR > 2.79; n = 64). Four other patient types, namely, benign nodular goiter, clinically nodal-positive (cN1) PTC, poorly differentiated thyroid carcinoma, and anaplastic thyroid carcinoma (ATC), were used as references. RESULTS Age at operation (p < 0.001) and tumor size (p = 0.037) significantly increased with higher NLR. First tertile had significantly more TNM stage I tumors (p = 0.01) and lowest MACIS score (p = 0.002). Tumor size [hazard ratio (HR) 1.422, 95% confidence interval (CI) 1.119-1.809, p = 0.004] and multicentricity (HR = 2.545, 95% CI 1.073-6.024, p = 0.034) independently predicted DFS, whereas old age [odds ratio (OR) 1.026, 95% CI 1.006-1.046, p = 0.009), male (OR 2.882, 95% CI 1.348-6.172, p = 0.006), and large tumor (OR 1.567, 95% CI 1.209-2.032, p = 0.001) independently predicted occult CNM. NLR was not significantly associated with DFS or occult CNM. ATC had significantly higher NLR than cN1 PTC (7.28 vs. 2.74, p < 0.001). CONCLUSIONS Although a higher NLR may imply a poorer tumor profile, it was not significantly associated with a worse DFS or higher risk of occult CNM in cN0 PTC. Perhaps, future research should focus on the prognostic value in other thyroid cancer types with a poorer prognosis.
Collapse
|
23
|
Lang BHH, Wong CKH. A cost-effectiveness comparison between early surgery and non-surgical approach for incidental papillary thyroid microcarcinoma. Eur J Endocrinol 2015; 173:367-75. [PMID: 26104754 DOI: 10.1530/eje-15-0454] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 06/23/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND The issue of whether all incidental papillary thyroid microcarcinoma (PTMC) should be managed by early surgery (ES) has been questioned and there is a growing acceptance that a non-surgical approach (NSA) might be more appropriate. We conducted a cost-effectiveness analysis comparing the two strategies in managing incidental PTMC. METHODS Our base case was a hypothetical 40-year-old female diagnosed with a unifocal intra-thyroidal 9 mm PTMC. The PTMC was considered suitable for either strategy. A Markov decision tree model was constructed to compare the estimated cost-effectiveness between ES and NSA after 20 years. Outcome probabilities, utilities and costs were derived from the literature. The threshold for cost-effectiveness was set at USD 50,000/quality-adjusted life year (QALY). A further analysis was done for patients < 40 and ≥ 40 years. Sensitivity and threshold analyses were used to examine model uncertainty. RESULTS Each patient who adopted NSA over ES cost an extra USD 682.54 but gained an additional 0.260 QALY. NSA was cost saving (i.e. less costly and more effective) up to 16 years from diagnosis and remained cost-effective from 17 years onward. In the sensitivity analysis, NSA remained cost-effective regardless of patient age (< 40 and ≥ 40 years), complications, rates of progression, year cycle and discount rate. In the threshold analysis, none of the scenarios that could have changed the conclusion appeared clinically likely. CONCLUSIONS For a selected group of incidental PTMC, adopting NSA was not only cost saving in the initial 16 years but also remained cost effective thereafter. This was irrespective of patient age, complication rate or rate of PTMC progression.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine SurgeryDepartment of Surgery, Queen Mary Hospital, University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, ChinaDepartment of Family Medicine and Primary Care3/F Ap Lei Chau Clinic, University of Hong Kong, 161 Main Street, Ap Lei Chau, Hong Kong, China
| | - Carlos K H Wong
- Division of Endocrine SurgeryDepartment of Surgery, Queen Mary Hospital, University of Hong Kong, 102 Pokfulam Road, Pokfulam, Hong Kong SAR, ChinaDepartment of Family Medicine and Primary Care3/F Ap Lei Chau Clinic, University of Hong Kong, 161 Main Street, Ap Lei Chau, Hong Kong, China
| |
Collapse
|
24
|
Lau ST, Zhou T, Liu JAJ, Fung EYM, Che CM, Lang BHH, Ngan ESW. Dysregulation of clathrin promotes thyroid cell growth and contributes to multinodular goiter pathogenesis. Biochim Biophys Acta Mol Basis Dis 2015; 1852:1676-86. [DOI: 10.1016/j.bbadis.2015.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 11/15/2022]
|
25
|
Lang BHH, Yu HW, Lo CY, Lee KE, Garcia-Barcelo MM, Woo YC, Lee PCH, Wong KP, Tam PKH, Lam KSL. Bilateral Pheochromocytomas in MEN2A Syndrome: A Two-Institution Experience. World J Surg 2015; 39:2484-91. [DOI: 10.1007/s00268-015-3117-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
26
|
Lang BHH, Wong CKH. Validation and Comparison of Nomograms in Predicting Disease-Specific Survival for Papillary Thyroid Carcinoma. World J Surg 2015; 39:1951-8. [DOI: 10.1007/s00268-015-3044-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
27
|
Affiliation(s)
- Eran Brauner
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, Hong Kong
| | - Kai-Pun Wong
- Department of Surgery, The University of Hong Kong, Hong Kong
| | - James A. Burns
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, Boston, Massachusetts
| | - Roy Phitayakorn
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sareh Parangi
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
28
|
Wong KP, Woo JW, Youn YK, Chow FCL, Lee KE, Lang BHH. The importance of sonographic landmarks by transcutaneous laryngeal ultrasonography in post-thyroidectomy vocal cord assessment. Surgery 2014; 156:1590-6; discussion 1596. [DOI: 10.1016/j.surg.2014.08.061] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
|
29
|
Abstract
BACKGROUND Insulinoma is a rare functional pancreatic neuroendocrine tumour (NET) believed to have an excellent long-term outcome, but few studies have solely focused on this issue after apparently curative resection. This study aimed to assess post-operative and long-term outcomes after resection of benign insulinomas. METHODS From 1998 to 2013, 36 consecutive patients with insulinomas underwent surgery. Three patients had multiple endocrine neoplasia type-1 (MEN-1). Demographics, operative findings, tumour grade (2010 World Health Organization (WHO) NET classification), post-operative pancreatic fistula (POPF) grade (International Study Group of Pancreatic Fistula (ISGPF)), complications and recurrence were analysed. RESULTS Eighteen (50%) had enucleation while the rest underwent pancreatic resection. The majority (86.1%) of insulinomas belonged to WHO NET grade G1. POPF occurred in 58.3% of patients while clinical fistula (ISGPF grades B and C) occurred in 19.4%. One (2.8%) patient required reoperation. The occurrence of POPF was not related to type of resection or surgical approach. There was no perioperative mortality. After a mean follow-up of 83.6 months, two patients (5.7%) developed disease recurrence at 34.4 and 131.9 months after initial surgery. No patients developed distant metastasis. The 10- and 15-year disease-free rates were 95.6 and 85.4%, respectively. CONCLUSION POPF occurred frequently and posed a significant morbidity after resection of insulinoma. However, it occurred independently of type of resection or surgical approach. Although the immediate cure rate after resection was high (100%), long-term disease recurrence in sporadic (non-MEN-1) cases was not insignificant. Regular long-term follow-up is recommended.
Collapse
Affiliation(s)
- Yi-Po Tsang
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Hong Kong
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, The University of Hong Kong, Hong Kong
| | | |
Collapse
|
30
|
Wong KP, Lang BHH, Chang YK, Wong KC, Chow FCL. Assessing the Validity of Transcutaneous Laryngeal Ultrasonography (TLUSG) After Thyroidectomy: What Factors Matter? Ann Surg Oncol 2014; 22:1774-80. [DOI: 10.1245/s10434-014-4162-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Indexed: 11/18/2022]
|
31
|
Lang BHH, Wong CKH, Tsang JS, Wong KP, Wan KY. A systematic review and meta-analysis evaluating completeness and outcomes of robotic thyroidectomy. Laryngoscope 2014; 125:509-18. [PMID: 25236330 DOI: 10.1002/lary.24946] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/06/2014] [Accepted: 09/04/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Despite immense interest, robotic-assisted thyroidectomy (RT) remains controversial in differentiated thyroid carcinoma (DTC). This systematic review and meta-analysis compared surgical completeness and/or oncological outcomes between RT and open thyroidectomy (OT) in low-risk DTC. STUDY DESIGN Systematic review. METHODS A systematic review was performed to identify studies that compared surgical completeness and/or oncological outcomes between RT and OT in DTC. Any study that compared at least one parameter relating to surgical completeness and/or oncological outcome for DTC was considered. Number of central lymph nodes (CLNs) retrieved during central neck dissection (CND), preablation stimulated thyroglobulin (sTg) level, radioiodine uptake on post-therapy scan, and locoregional recurrence (LRR) were examined. Meta-analysis was performed using a fixed or random-effects model depending on heterogeneity between studies. RESULTS Ten studies were eligible. Of the 2,205 DTCs, 752 (34.1%) had RT, whereas 1,453 (65.9%) had OT. Relative to OT, RT had significantly fewer CLNs retrieved during CND (4.7 ± 3.2 vs. 5.5 ± 3.8, standardized mean difference [SMD] = -0.240, 95% confidence interval [CI]: -0.364 to -0.116, P < .001) and higher preablation sTg level (3.6 ± 6.7 ng/mL vs. 2.0 ± 5.0 ng/mL, SMD = 0.272, 95% CI: 0.022 to 0.522, P = .033). Interestingly, these differences were more evident in the robotic transaxillary approach (RTAA) than the robotic bilateral axillo-breast approach. After a mean follow-up of 17.7 months, no LRR was found in RT, whereas after 18.6 months, one LRR was found in OT. CONCLUSIONS Relative to OT, total thyroidectomy by RTAA was associated with fewer CLNs retrieved and less-complete thyroid resection. However, using RTAA is unlikely to compromise the outcomes of low-risk DTC because of its inherently good prognosis.
Collapse
|
32
|
Lang BHH, Lo CY, Wong KP, Wan KY. Long-Term Outcomes for Older Patients with Papillary Thyroid Carcinoma: Should Another Age Cutoff Beyond 45 Years Be Added? Ann Surg Oncol 2014; 22:446-53. [DOI: 10.1245/s10434-014-4055-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Indexed: 01/15/2023]
|
33
|
Lang BHH, Chan DTY, Wong KP, Wong KKC, Wan KY. Predictive Factors and Pattern of Locoregional Recurrence After Prophylactic Central Neck Dissection in Papillary Thyroid Carcinoma. Ann Surg Oncol 2014; 21:4181-7. [DOI: 10.1245/s10434-014-3872-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Indexed: 01/28/2023]
|
34
|
Lang BHH, Wong KP. How useful are perioperative biochemical parameters in predicting the duration of calcium and/or vitamin D supplementation after total thyroidectomy? World J Surg 2014; 37:2581-8. [PMID: 23982779 DOI: 10.1007/s00268-013-2195-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Oral calcium and calcitriol are often prescribed after total thyroidectomy to avoid biochemical and/or symptomatic hypocalcemia. We aimed to identify independent perioperative factors that correlated with the duration of calcium and/or calcitriol supplementation after total thyroidectomy. METHODS Of 271 eligible patients, 48 (17.7 %) required calcium and/or calcitriol supplements on discharge. Patients were gradually weaned from the supplementation by one surgeon according to a biweekly algorithm based on serum calcium (Ca). Duration of supplementation was calculated from the date of operation to the date of ceasing all supplementation without biochemical hypocalcemia (i.e., serum adjusted Ca ≥ 8.44 mg/dL). The Cox regression analysis was performed to identify independent perioperative factors for duration of supplementation. The best cut-off value for these independent factors was determined by the receiver characteristic curve. RESULTS In the multivariate analysis, parathyroid hormone (PTH) at skin closure (PTH-SC) (RR 1.742, 95 % CI 1.080-2.810) and on postoperative day 1 adjusted Ca (Ca-D1) (RR 77.526, 95 % CI 3.600-1669.57) were the only two independent determinants for shorter duration before ceasing all supplementation. The best cut-off values in predicting supplementation ≥ 6 months for PTH-SC and Ca-D1 were 7.08 pg/mL (sensitivity = 100 %, specificity = 60.5 %, PPV = 40.0 % and NPV = 100 %) and 7.88 mg/dL (sensitivity = 90.0 %, specificity = 55.3 %, PPV = 34.6 % and NPV = 95.5 %), respectively. CONCLUSIONS Both PTH-SC and Ca-D1 were independently associated with the duration of supplementation after total thyroidectomy. Almost all patients with PTH-SC ≥ 7.08 pg/mL or Ca-D1 ≥ 7.88 mg/dL did not require supplementation ≥ 6 months whereas about one third of patients with PTH-SC <7.08 pg/mL or Ca-D1 <7.88 mg/dL required supplementation ≥ 6 months.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China,
| | | |
Collapse
|
35
|
Lang BHH, Wong CKH, Tsang RKY, Wong KP, Wong BYH. Evaluating the Cost-Effectiveness of Laryngeal Examination after Elective Total Thyroidectomy. Ann Surg Oncol 2014; 21:3548-56. [DOI: 10.1245/s10434-014-3770-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Indexed: 12/16/2022]
|
36
|
Lang BHH, Ng SH, Wong KP. Pain and surgical outcomes with and without neck extension in standard open thyroidectomy: A prospective randomized trial. Head Neck 2014; 37:407-12. [DOI: 10.1002/hed.23611] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 11/09/2013] [Accepted: 01/09/2014] [Indexed: 12/26/2022] Open
Affiliation(s)
- Brian Hung-Hin Lang
- Department of Surgery; University of Hong Kong; Pokfulam Hong Kong SAR China
| | - Sze-How Ng
- Department of Surgery; Kuala Lumpur Hospital; Kuala Lumpur Malaysia
| | - Kai Pun Wong
- Department of Surgery; University of Hong Kong; Pokfulam Hong Kong SAR China
| |
Collapse
|
37
|
Lang BHH, Wong CKH, Tsang JS, Wong KP. A systematic review and meta-analysis comparing outcomes between robotic-assisted thyroidectomy and non-robotic endoscopic thyroidectomy. J Surg Res 2014; 191:389-98. [PMID: 24814766 DOI: 10.1016/j.jss.2014.04.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/19/2014] [Accepted: 04/09/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite its feasibility, using the da Vinci robot in remote-access thyroidectomy remains controversial. This meta-analysis compared surgical and oncological outcomes between robotic-assisted thyroidectomy (RT) and non-robotic endoscopic thyroidectomy (ET). METHODS A systematic review was performed to identify studies comparing outcomes between RT and ET. Outcomes included operating time, drain output, complications, number of central lymph nodes retrieved, and preablation stimulated thyroglobulin level. A random-effects model was used. RESULTS Six studies were eligible. Of the 3510 patients, 2167 (61.7%) underwent RT whereas 1343 (38.3%) underwent ET. Despite a higher drain output (185.8 mLs versus 173.3 mLs, P = 0.019), RT had fewer temporary recurrent laryngeal nerve injury (2.6% versus 3.3%, P = 0.035) and shorter length of hospital stay (3.4 d versus 3.5 d, P = 0.030). In terms of oncological outcomes, despite higher incidence of multicentricity and larger tumors, the number of central lymph nodes retrieved during unilateral central neck dissection in RT was significantly greater than ET (4.5 ± 2.6 and 3.4 ± 2.5, P < 0.001) whereas the preablation stimulated thyroglobulin was comparable (0.8 ng/mL versus 1.1 ng/mL, P = 0.456). However, follow-up data were relatively scarce. CONCLUSIONS Adding the robot in remote-access thyroidectomy was associated with a significantly lower risk of temporary recurrent laryngeal nerve injury and shorter length of hospital stay. However, despite achieving a comparable level of surgical completeness for low-risk differentiated thyroid carcinoma between RT and ET, this study highlighted the limitations with the current literature and the need for more prospective studies with adequate follow-up.
Collapse
Affiliation(s)
| | - Carlos K H Wong
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Julian Shun Tsang
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Kai Pun Wong
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| |
Collapse
|
38
|
Abstract
Utilizing BRAF(V600E) mutation as a marker may reduce unnecessary prophylactic central neck dissection (pCND) in clinically nodal negative (cN0) neck for small (≤2 cm) classical papillary thyroid carcinoma (PTC). We aimed to assess whether BRAF is a significant independent predictor of occult central nodal metastasis (CNM) and its contribution to the overall prediction after adjusting for other significant preoperative clinical factors in small PTC. Primary tumor tissue (paraffin-embedded) from 845 patients with small classical cN0 PTC who underwent pCND was tested for BRAF mutation. Clinicopathologic factors were compared between those with and without BRAF. BRAF was evaluated to see if it was an independent factor for CNM. Prediction scores were generated using logistic regression models and their predictability was measured by the area under the ROC curve (AUC). The prevalence of BRAF was 628/845 (74.3%) while the rate of CNM was 285/845 (33.7%). Male sex (odds ratio (OR): 2.68, 95% CI: 1.71-4.20), large tumor size (OR: 2.68, 95% CI: 1.80-4.00), multifocality (OR: 1.49, 95% CI: 1.07-2.09), lymphovascular permeation (OR: 10.40, 95% CI: 5.18-20.88), and BRAF (OR: 1.65, 95% CI: 1.10-2.46) were significant independent predictors of CNM, while coexisting Hashimoto's thyroiditis (OR: 0.56, 95% CI: 0.40-0.80) was an independent protective factor. The AUC for prediction score based on tumor size and male sex was similar to that of prediction score based on tumor size, male sex, and BRAF status (0.68 vs 0.69, P=0.60). Although BRAF was an independent predictor of CNM, knowing its status did not substantially improve the overall prediction. A simpler prediction score based on male sex and tumor size might be sufficient.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China Department of Surgery, Seoul National University College of Medicine and Hospital, Seoul, Korea School of Public Health, The University of Hong Kong, Hong Kong SAR, China Department of Pathology, Seoul National University College of Medicine and Hospital, Seoul, Korea Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | | | | | | | | | | |
Collapse
|
39
|
Chang RYK, Lang BHH, Chan AC, Wong KP. Evaluating the efficacy of primary treatment for graves' disease complicated by thyrotoxic periodic paralysis. Int J Endocrinol 2014; 2014:949068. [PMID: 25147568 PMCID: PMC4131447 DOI: 10.1155/2014/949068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 06/22/2014] [Accepted: 07/14/2014] [Indexed: 12/18/2022] Open
Abstract
Objective. Thyrotoxic periodic paralysis (TPP) is a potentially life-threatening complication of Graves' disease (GD). The present study compared the long-term efficacy of antithyroid drugs (ATD), radioactive iodine (RAI), and surgery in GD/TPP. Methods. Sixteen patients with GD/TPP were followed over a 14-year period. ATD was generally prescribed upfront for 12-18 months before RAI or surgery was considered. Outcomes such as thyrotoxic or TPP relapses were compared between the three modalities. Results. Eight (50.0%) patients had ATD alone, 4 (25.0%) had RAI, and 4 (25.0%) had surgery as primary treatment. Despite being able to withdraw ATD in all 8 patients for 37.5 (22-247) months, all subsequently developed thyrotoxic relapses and 4 (50.0%) had ≥1 TPP relapses. Of the four patients who had RAI, two (50%) developed thyrotoxic relapse after 12 and 29 months, respectively, and two (50.0%) became hypothyroid. The median required RAI dose to render hypothyroidism was 550 (350-700) MBq. Of the 4 patients who underwent surgery, none developed relapses but all became hypothyroid. Conclusion. To minimize future relapses, more definitive primary treatment such as RAI or surgery is preferred over ATD alone. If RAI is chosen over surgery, a higher dose (>550 MBq) is recommended.
Collapse
Affiliation(s)
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong
- *Brian Hung-Hin Lang:
| | - Ai Chen Chan
- Department of Surgery, The University of Hong Kong, Hong Kong
| | - Kai Pun Wong
- Department of Surgery, The University of Hong Kong, Hong Kong
| |
Collapse
|
40
|
Wong CKH, Lang BHH. A Cost-Utility Analysis for Prophylactic Central Neck Dissection in Clinically Nodal-Negative Papillary Thyroid Carcinoma. Ann Surg Oncol 2013; 21:767-77. [DOI: 10.1245/s10434-013-3398-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Indexed: 01/08/2023]
|
41
|
Wong KP, Lang BHH, Ng SH, Cheung CY, Chan CTY, Chan MY. Is Vocal Cord Asymmetry Seen on Transcutaneous Laryngeal Ultrasonography a Significant Predictor of Voice Quality Changes After Thyroidectomy? World J Surg 2013; 38:607-13. [DOI: 10.1007/s00268-013-2337-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
42
|
Lang BHH, Wong CKH, Tsang JS, Wong KP, Wan KY. A systematic review and meta-analysis comparing surgically-related complications between robotic-assisted thyroidectomy and conventional open thyroidectomy. Ann Surg Oncol 2013; 21:850-61. [PMID: 24271160 DOI: 10.1245/s10434-013-3406-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite gaining popularity, robotic-assisted thyroidectomy (RT) remains controversial. This systematic review and meta-analysis is aimed at comparing surgically-related complications between RT and conventional open thyroidectomy (OT). METHODS A systematic review of the literature was performed to identify studies comparing surgically-related outcomes between RT and OT. Studies that compared ≥ 1 surgically-related outcomes between RT and OT were included. Outcomes included operating time, blood loss, complications, and hospital stay. Meta-analysis was performed using a fixed-effects model. RESULTS Eleven studies were eligible but none were randomized controlled trials. Of the 2,375 patients, 839 (35.3 %) underwent RT, while 1,536 (64.7 %) underwent OT. RT was significantly associated with longer operating time (p < 0.001), hospital stay (p = 0.023) and higher temporary recurrent laryngeal nerve (RLN) injury (p = 0.016). Although there was no correlation between the number of RTs reported in the study and the rate of temporary RLN injury (p = -0.486, p = 0.328, respectively), routine perioperative laryngoscopy was performed in only 2 of 11 studies. Blood loss (p = 0.485), temporary (p = 0.333) and permanent (p = 0.599) hypocalcemia, hematoma (p = 0.602), and overall morbidity (p = 0.880) appeared comparable. Two (0.2 %) brachial plexus injuries in RT were reported in one study. CONCLUSIONS Relative to OT, RT was associated with significantly longer operating time, longer hospital stay, and higher temporary RLN injury rate but comparable permanent complications and overall morbidity. Given some of the limitations with the literature and the potential added surgical risks and morbidity in RT, application of the robot in thyroid surgery should be carefully and thoroughly discussed before one decides on the procedure.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, Hong Kong SAR, China,
| | | | | | | | | |
Collapse
|
43
|
Lang BHH, Ng SH, Lau LLH, Cowling BJ, Wong KP, Wan KY. A systematic review and meta-analysis of prophylactic central neck dissection on short-term locoregional recurrence in papillary thyroid carcinoma after total thyroidectomy. Thyroid 2013; 23:1087-98. [PMID: 23402640 DOI: 10.1089/thy.2012.0608] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prophylactic central neck dissection (pCND) at the time of total thyroidectomy (TT) remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma (PTC). Despite occult central lymph node metastases being common, it is unclear if removing these metastases initially would reduce future locoregional recurrence (LRR). This systematic review and meta-analysis aimed at comparing the short-term LRR between patients who underwent TT with pCND and those who underwent TT alone. METHODS A systematic review of the literature was performed to identify studies comparing LRR between patients with PTC who underwent TT + pCND (group A) and those who underwent TT alone (group B). Inclusion criteria were cN0 patients, with each comparative group containing > 10 patients, and with the number of LRR and mean follow-up duration available. The pooled incidence rate ratio (IRR) was used for calculating the LRR rate between the two groups. Other parameters evaluated included postoperative radioiodine (RAI) ablation, surgically related complications, and overall morbidity. Meta-analysis was performed using a fixed-effects model. RESULTS Fourteen studies matched the selection criteria. Of the 3331 patients, 1592 (47.8%) belonged to group A, while 1739 (52.2%) belonged to group B. Relative to group B, group A was significantly more likely to have postoperative RAI ablation (71.7% vs. 53.1%; odds ratio [OR] = 2.60 [95% confidence interval (CI) = 2.12-3.18]), temporary hypocalcemia (26.0% vs. 10.8%; OR = 2.56 [CI = 2.04-3.21]), and overall morbidity (33.2% vs. 17.7%; OR = 2.12 [CI = 1.75-2.57]). When temporary hypocalcemia was excluded, overall morbidity was similar between the two groups (7.3% vs. 6.8%; OR = 1.07 [CI = 0.78-1.47]). Group A had a significantly lower risk of LRR than group B (4.7% vs. 8.6%; IRR = 0.65 [CI = 0.48-0.86]). CONCLUSIONS Group A was more likely to have postoperative RAI ablation, temporary hypocalcemia, and overall morbidity than group B. Temporary hypocalcemia was the major surgical morbidity in pCND and, when excluded, the overall morbidity appeared similar between the two groups. Although our meta-analysis would suggest that those who undergo TT + pCND may have a 35% reduction in risk of LRR than those who undergo TT alone in the short term (< 5 years), it remains unclear how much of this risk reduction is related to increased use of RAI ablation and potential selection bias in some of the studies examined.
Collapse
|
44
|
Lang BHH, Wong CKH. A cost-minimization analysis comparing total thyroidectomy alone and total thyroidectomy with prophylactic central neck dissection in clinically nodal-negative papillary thyroid carcinoma. Ann Surg Oncol 2013; 21:416-25. [PMID: 23982258 DOI: 10.1245/s10434-013-3234-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND Total thyroidectomy (TT) with prophylactic central neck dissection (pCND) remains controversial for clinically nodal-negative (cN0) papillary thyroid carcinoma (PTC), and the issue of cost rarely has been examined. We evaluated whether pCND at the time of TT is more cost-saving than TT alone in the medium- to long-term. METHODS For a hypothetical group of 50-year-old females with a 1.5-cm cN0 PTC, a decision-tree model using TreeAge Software was developed to simulate outcomes and compare the 20-year accumulative direct cost between TT alone and TT+pCND strategies. Baseline values and ranges were determined from a systematic review of the literature. Sensitivity analyses were conducted to test model strength. Cost estimate of surgical procedures, complications, and radioiodine (RAI) ablation was based on government gazette. RESULTS The cost accrued per patient for the primary operation under TT alone and TT+pCND strategies were USD 6,702.81 and USD 10,062.35, respectively, whereas the cost for the reoperative procedure were USD 12,981.40 and USD 12,509.09, respectively. The 20-year accumulative cost for TT alone and TT+pCND strategies were USD 19,888.36 and USD 22,760.86, respectively. The incremental cost per patient was USD 2,872.50. In the univariate and bivariate sensitivity analyses, no change in conclusion was seen by varying the rates of complications, annualized locoregional recurrences and RAI, or by extending the model to 50 years. CONCLUSIONS From a pure economic institution's perspective, TT+pCND is more expensive in the medium- and long-term and seems less justified compared with TT alone for cN0 PTC.
Collapse
Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China,
| | | |
Collapse
|
45
|
Lang BHH, Lo CY, Wong KP, Wan KY. Should an Involved but Functioning Recurrent Laryngeal Nerve be Shaved or Resected in a Locally Advanced Papillary Thyroid Carcinoma? Ann Surg Oncol 2013; 20:2951-7. [DOI: 10.1245/s10434-013-2984-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Indexed: 11/18/2022]
|
46
|
Lang BHH, Yih PCL, Hung GKY. Does using an energized device in open thyroidectomy reduce complications? J Surg Res 2013; 181:e23-9. [DOI: 10.1016/j.jss.2012.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 05/12/2012] [Accepted: 06/04/2012] [Indexed: 01/03/2023]
|
47
|
Ng SH, Lang BHH. Parathyroid carcinoma in a 30-year-old man: a diagnostic and management challenge. World J Surg Oncol 2013; 11:83. [PMID: 23566353 PMCID: PMC3623658 DOI: 10.1186/1477-7819-11-83] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 03/23/2013] [Indexed: 11/16/2022] Open
Abstract
Parathyroid carcinoma is a rare endocrine malignancy, accounting for less than 1% of cases of primary hyperparathyroidism. Patient-related factors such as age and sex, as well as the biological features and management of the cancer, influence mid-term and long-term survival. We report a case of a young man with an unusual presentation of parathyroid carcinoma. The patient presented with left thigh swelling, which had been present for 6 months without other symptoms of hypercalcemia. On computed tomography scan a hypodense lesion, 30 × 20 × 20 mm in size, was seen in the posterior thyroid. There was no evidence of cervical lymphadenopathy or local infiltration. On a Sestamibi scan, a hot spot was seen in the lower pole of left thyroid lobe. Cervical neck exploration was performed. The patient subsequently underwent surgery and a parathyroid tumor was excised. The tumor was adherent to the thyroid capsule, but there was no evidence of invasion. After surgery, the patient’s calcium and parathyroid hormone levels normalized, but histology confirmed parathyroid carcinoma with capsular and vascular invasion. The patient was offered reoperation, but declined, and developed recurrent parathyroid carcinoma 2 years later. In this report, we aim to present the challenges in managing parathyroid carcinoma and discuss factors that might contribute to future locoregional recurrences. This case also highlighted several issues, including the challenge of ascertaining the diagnosis before surgery and the dilemma of reoperation after simple excision.
Collapse
Affiliation(s)
- Sze-How Ng
- Breast & Endocrine Unit, Department of Surgery, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | | |
Collapse
|
48
|
Abstract
Background Although postoperative hematoma after thyroidectomy is uncommon, patients traditionally have been advised to stay overnight in the hospital for monitoring. With the growing demand for outpatient thyroidectomy, we assessed its safety and feasibility by evaluating the potential risk factors and timing of postoperative hematoma after thyroidectomy. Methods From 1995–2011, 3,086 consecutive patients underwent thyroidectomy at our institution; of these, 22 (0.7 %) developed a postoperative hematoma that required surgical reexploration (group I). Potential risk factors were compared between group I and those without hematoma (n = 3,045) or with hematoma but not requiring reexploration (n = 19; group II). Variables that were significant in the univariate analysis were entered into multivariate analysis by binary logistic regression analysis. Results Group I was significantly more likely to have undergone previous thyroid operation than group II (27.3 vs. 8.2 %, p = 0.007). The median weight of excised thyroid gland (71.8 vs. 40 g, p = 0.018) and the median size of the dominant nodule (4.1 vs. 3 cm, p = 0.004) were significantly greater in group I than group II. Previous thyroid operation (odds ratio (OR) = 4.084; 95 % confidence interval (CI), 1.105–15.098; p = 0.035) and size of dominant nodule (OR = 1.315; 95 % CI, 1.024–1.687; p = 0.032) were independent factors for hematoma. Sixteen (72.7 %) had hematoma within 6 h, whereas the other 6 (27.3 %) had hematoma at 6–24 h. Conclusions Previous thyroid operation and large dominant nodule were independent risk factors for hematoma requiring surgical reexploration. Given that a quarter of hematoma occurred between 6 to 24 h after surgery, routine outpatient thyroidectomy could not be recommended.
Collapse
|
49
|
Lang BHH, Wong KP, Cheung CY, Fong YK, Chan DKK, Hung GKY. Does Preoperative 25-Hydroxyvitamin D Status Significantly Affect the Calcium Kinetics after Total Thyroidectomy? World J Surg 2013; 37:1592-8. [DOI: 10.1007/s00268-013-2015-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
50
|
Lang BHH, Ng SH, Lau LL, Cowling BJ, Wong KP. A Systematic Review and Meta-analysis Comparing the Efficacy and Surgical Outcomes of Total Thyroidectomy Between Harmonic Scalpel Versus Ligasure. Ann Surg Oncol 2013; 20:1918-26. [DOI: 10.1245/s10434-012-2849-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Indexed: 11/18/2022]
|