Partial Thyroidectomy With Incidental Metastatic Lymph Nodes

Importance

The need for completion thyroidectomy in patients with incidental metastatic lymph nodes after partial thyroidectomy is unclear.

Objective

To investigate the outcomes of patients with incidental metastatic lymph nodes following partial thyroidectomy.

Design, Setting, and Participants

A retrospective review of a prospectively maintained thyroid cancer database from 1985 to 2015 was carried out at a head and neck surgery practice at a tertiary referral cancer center. A total of 74 patients who underwent thyroid lobectomy or thyroid isthmusectomy between 1985 and 2015 and were found to have incidental metastatic lymph nodes on final pathologic analysis and were selected to be observed without immediate completion thyroidectomy were included. A separate group of additional 11 patients who underwent immediate completion thyroidectomy was also identified and reviewed.

Main Outcome and Measure

Analysis took place from February to May 2022. Recurrence-free survival outcomes of patients found to have incidental metastatic lymph nodes on final pathologic analysis following partial thyroidectomy with no immediate completion thyroidectomy.

Results

A total of 74 patients were observed, with a median (IQR) age of 39 (28-49) years; 44 (59%) were women. Sixty-four patients underwent thyroid lobectomy and 10 patients had isthmusectomy. Classic papillary thyroid carcinoma was the most common histologic type (34 [46%]). Vascular invasion and microscopic extrathyroidal extension were present in 11 patients (16%) and 22 patients (30%), respectively. Positive margins were identified in 5 patients (7.8%). Size of metastatic lymph nodes ranged between 0.07 cm and 1.2 cm. No extranodal extension was reported. A total of 52 patients (70%) were classified as intermediate risk for recurrence based on the American Thyroid Association risk stratification system. The median (IQR) follow up was 48.15 (15.4-86.1) months, during which only 1 patient had a regional recurrence. Another patient underwent delayed completion thyroidectomy for a contralateral lobe malignant abnormality. Recurrence-free survival, disease-specific survival, and overall survival were 97.4%, 100%, and 96.2%, respectively. A separate group of 11 patients who underwent immediate completion thyroidectomy were reviewed. These patients were more likely to have tall-cell papillary thyroid carcinoma (6 [55%] vs 13 [18%]), multifocality (9 [82%] vs 28 [41%]), microscopic extrathyroidal extension (8 [73%] vs 22 [30%]), and positive margins (3 [30%] vs 5 [7.8%]) compared with patients who were under observation only.

Conclusion and Relevance

Completion thyroidectomy may not be necessary in appropriately selected patients who are found to have incidental metastatic lymph nodes (N1a) after partial thyroidectomy for localized well-differentiated thyroid cancer.

The role of surgery for anaplastic thyroid carcinoma in the era of targeted therapeutics: A scoping review

Background

Questions exist regarding patient selection for surgery in anaplastic thyroid carcinoma (ATC), particularly with the advent of neoadjuvant-targeted therapeutics. The present scoping review sought to evaluate what extent of surgical resection should be performed in ATC.

Methods

A scoping review was carried out in accordance with Joanna Briggs Institute and the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) protocols. Included studies were required to provide clear description of the surgery performed for ATC.

Results

The final search identified 6901 articles. Ultimately only 15 articles including 1484 patients met inclusion criteria. A total of 765 patients (51.5%) underwent attempted curative intent surgery. The approach to resection of adjacent tissues varied between studies. Eight studies considered laryngeal ± pharyngeal resection (8/15, 53.3%), eight studies (53.3%) considered tracheal resection and again eight studies (53.3%) considered esophageal resection. More extensive resections increased morbidity without improving overall survival (OS) (<9 months in the 12 studies using a combination of surgery and chemoradiotherapy). In the three studies utilizing targeted therapy in addition to surgery, OS was notably improved while surgical resection following neoadjuvant therapy was less extensive.

Conclusions

There is no clear agreement in the literature regarding the limits of surgical resection in locoregionally advanced ATC. A definition of surgically resectable disease will be required to guide surgical decision making in ATC, particularly with the potential to reduce tumor burden using neoadjuvant targeted treatment in suitable patients.

Level of evidence

III.

Surgical management of T1/T2 node-negative papillary thyroid cancer with tall cell histology: Is lobectomy enough?

BACKGROUND

The tall cell variant of papillary thyroid carcinoma has traditionally been treated more aggressively than classic papillary thyroid carcinoma. However, this may not be justified in patients with T1/T2 tall cell variant node-negative tumors.

METHODS

We evaluated well-differentiated thyroid cancers treated surgically between 1985 and 2015 at our institution. We compared patients undergoing lobectomy for node-negative T1/T2 tall cell variant tumors with the same cohort with classic papillary thyroid carcinoma. Patients who underwent early planned completion thyroidectomy were excluded. Tall cell variant tumors were defined as those with ≥30% tall cells. Survival and recurrence outcomes were determined by the Kaplan-Meier method and groups compared using the log-rank test.

RESULTS

Thyroid lobectomy was performed for T1/T2 N0X disease in 70 (15%) tall cell cases and 429 (23%) classic papillary thyroid carcinoma cases. There was no significant difference in 10-year overall survival (P = .56) or locoregional recurrence-free probability (P = .52). Disease-specific survival and local or central nodal recurrence-free probability were 100% in both groups. In 9 papillary thyroid carcinoma cases, subsequent contralateral lobe tumors developed, and in 5, lateral neck metastases developed. No recurrences were seen in the tall cell group.

CONCLUSION

T1 node-negative tumors with tall cell histology can be satisfactorily managed with thyroid lobectomy, with equivalent oncological outcomes to classic papillary thyroid carcinoma.

Analysis of Outcomes of Pharyngo-laryngo-esophagectomy and Reconstruction with Longitudinal Comparison in a Single Institution

Advanced hypopharyngeal tumours present complex clinical challenges, and where resection is attempted, there is a requirement for major reconstruction. Despite advances in surgical technique, outcomes remain poor for this patient group, and optimum treatment has yet to be established. We aimed to assess the treatment and outcomes of patients in our institution in the context of previous studies. All patients from 2008 to 2018 who underwent surgical management for hypopharyngeal tumours with pharyngo-laryngo-esophagectomy and flap-based reconstruction were included in the study. Demographic and outcome data were collected, and patient-reported outcomes were solicited from surviving patients using the EORTC QLQ H&N 43 questionnaire. Thirty patients were assessed, in which 12 had gastric pull-ups, 16 had free jejunum flaps, and 2 had free anterolateral thigh flaps. There was a 38% five-year survival rate. Overall, the rates of stricture (10.7%) and fistula (7.1%) were low. The majority of patients (53.6%) returned to a normal diet within three months with a soft or puree diet in 35.7% of patients. Some form of speech was possible in 92.9% of patients. The average questionnaire score for surviving patients was 87.3, with good outcomes related to eating and swallowing, but poorer outcomes for speech and communication. This study showed that outcomes for patients receiving complex reconstruction following hypopharyngeal tumour resection are improving over time. There is still scope for improvement of patient outcomes and refinement of optimum surgical management strategies.

Management of Temporal Bone Malignancy in Ireland

Objectives  Lateral temporal bone malignancy remains a challenging rare disease. We report 17 years of multidisciplinary care of these tumors with univariate and multivariate analyses of key prognostic indicators for consideration in contemporary oncological management. Design  This is a retrospective cohort study. Setting  This is set at a tertiary referral center. Participants  All patients presenting with histopathologically newly diagnosed cases of temporal bone malignancy between 2000 and 2017 were included. Main Outcome Measures  The main outcome measures are disease-specific and recurrence-free survival rates. Results  In this study, 48 cases of temporal bone malignancy were diagnosed. Median age at diagnosis was 69 years (range: 5-88). Fourteen patients were female. Squamous cell carcinoma was the predominant malignancy in 34 cases (71%). Surgical treatment was undertaken in 37 patients. Mean length of follow-up was 32 months (range: 0.7-117). Overall 5-year disease-specific survival was 52.4%, while overall 5-year recurrence-free survival was 53.5%. On univariate analysis, significantly worse survival was seen in females ( p  = 0.008), those with distant metastatic disease ( p  = 0.041), and in middle ear involvement ( p  = 0.012) with no difference for involvement of the external auditory canal ( p  = 0.98) or mastoid ( p  = 0.78). Only middle ear involvement remained significant on multivariate analysis. Conclusion  A wide variety of malignant pathology may present in the temporal bone. Recurrence-free survival is equivalent to international data; however, this figure is low. This emphasizes the need to treat these tumors appropriately with radical resection, where possible, at first presentation. Therefore, multidisciplinary surgical input is recommended. Middle ear involvement was a negative prognosticator for disease-specific and recurrence-free survivals.

Outcomes of endoscopic orbital decompression for graves' ophthalmopathy

BACKGROUND/AIMS

We assess outcomes of endoscopic orbital decompression for Graves' ophthalmopathy.

METHODS

A review of endoscopic orbital decompressions of the medial and partial inferior wall between July 2004 and July 2017 was carried out. Outcome was assessed by comparing pre- and post-operative measurements of exophthalmometry and visual acuity. Results were evaluated by repeated measures analysis of variance.

RESULTS

A total of 41 orbits in 25 patients underwent endoscopic orbital decompression for Graves' ophthalmopathy in the time period; however, six orbits in three patients had insufficient data for inclusion. Eleven patients required concurrent septoplasty to allow access. Measurements were taken at a mean of 11 days, 32 days, and 95 days post-operatively. Reduction in mean proptosis was 2.81 mm at 1-month post-decompression and 3.26 mm at 3 months. There was no significant difference between those treated for compressive optic neuropathy compared with those treated for cosmetic reasons. Colour vision by Ishihara plate improved significantly by a mean score of 2.67 post-operatively. Using LogMAR conversion for visual acuity, measured by a best-corrected Snellen chart, improvement of 0.18 was achieved at 1-month post-decompression, equivalent to approximately two lines on the Snellen chart. There was minimal (0.04) further improvement at 3 months. The improvement in visual acuity was greater in cases treated for compressive optic neuropathy than cosmesis, but this did not reach statistical significance (p = 0.06). Three cases required revision surgery. Diplopia disimproved or developed in four cases and squint surgery was required in three cases.

CONCLUSIONS

Endoscopic orbital decompression offers an effective, safe and minimally invasive treatment for Graves' ophthalmopathy. There is a trend towards continued improvement in outcomes over the course of 3 months post-operatively.

Outcomes of transoral laser microsurgery for oropharyngeal squamous cell carcinoma in Ireland and review of the literature on transoral approaches

BACKGROUND

The optimal treatment for oropharyngeal squamous cell carcinoma (OPSCC) is controversial. There is increasing evidence that, in selected cases, minimally invasive transoral surgery can offer improved functional outcomes, with equivalent oncologic outcomes, compared to chemoradiotherapy.

AIMS

We report the outcomes of transoral laser microsurgery (TLM) for treatment of OPSCC at our institution.

METHODS

Patients with OPSCC undergoing TLM at the South Infirmary Victoria University Hospital, Cork, between 2010 and 2016, were identified from an institutional database. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry. Survival outcomes were analysed using the Kaplan-Meier method. Complications following surgery and gastrostomy tube dependence were evaluated.

RESULTS

The study cohort consisted of 26 patients, with mean age of 56 years (range 29-71). Primary tumours were located in the tonsil (18), base of tongue (4) and other subsites (4). Seventeen cases were p16-positive. Complications included haemorrhage necessitating return to theatre (1) and aspiration pneumonia (1). Four patients underwent tracheostomy, all of whom were successfully decannulated. One patient underwent gastrostomy tube insertion during postoperative radiotherapy. No patient was gastrostomy dependent at latest follow-up. Twenty-two patients received adjuvant treatment, with radiation alone (21) or chemoradiotherapy (2). Mean follow-up was 27 months. Five-year locoregional control was 92% and disease-specific survival was 81%.

CONCLUSIONS

In selected patients with OPSCC, TLM offers excellent functional and survival outcomes, and as such offers an alternative approach to chemoradiotherapy as primary treatment. We compare TLM to other transoral approaches and discuss its potential use in the Irish healthcare system.

Changing Trends in the Management of Esthesioneuroblastoma: Irish and International Perspectives

Objectives  Evaluation of the changing trends in esthesioneuroblastoma in an Irish context and review of management options nationally to clarify the best current therapeutic approach by comparing with international research on this uncommon malignancy. Design  Retrospective review. Setting  Tertiary referral center. Participants  All patients presenting with esthesioneuroblastoma in Beaumont hospital or on the National Cancer Registry of Ireland between 1994 and 2013. Main Outcome Measures  Recurrence-free and overall survival. Results  During the study period, 32 cases of esthesioneuroblastoma were diagnosed (0.4 per million per year). Average age at diagnosis was 57 years; however, two cases were under 20. The majority (62.5%) were male. Patients predominantly presented with epistaxis or nasal congestion (73%), while two cases were identified incidentally on radiological investigations. Twenty-seven cases underwent primary surgical management (two post neo-adjuvant treatment) with seventeen requiring bifrontal craniotomy. Twenty-four of these received postoperative radiation therapy. Overall, 5-year survival was 65%. Kadish A/B patients exhibited 100% 5-year disease-specific survival versus 54% in Kadish C/D ( p  = 0.011). Hyams grade I/II patients exhibited 75% 5-year disease-specific survival versus 63% in Hyams grade III/IV ( p  = 0.005). Patients treated endoscopically exhibited 100% 5-year disease-specific survival versus 51% in those treated via an open approach ( p  = 0.102). Conclusions  Many controversies exist in the diagnosis and management of this condition. Despite this, results from Irish data are mostly concordant with the international literature. The rising incidence of this disease may represent improved pathological recognition. An increasing number of esthesioneuroblastoma cases are being successfully treated via endoscopic surgery.

Cytokeratin 7 in Oropharyngeal Squamous Cell Carcinoma: A Junctional Biomarker for Human Papillomavirus-Related Tumors

Background: Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (SCC) represents a distinct subgroup of head and neck tumors. We analyze the expression of cytokeratin 7, a junctional biomarker with a SEQIKA fragment, which stabilizes HPV-16 E7 transcripts, in oropharyngeal SCCs.Methods: Archived tumor specimens and epidemiologic data were collected from patients with oropharyngeal SCCs over 10 years. Briefly, DNA was extracted from tissue blocks, and HPV testing was carried out using SPF10 HPV PCR and INNO-LiPA HPV Genotyping. Immunohistochemical staining for CK7 and p16ink4a was performed on the Ventana BenchMark Ultra Immunostainer. Analysis was by light microscopy using the H-score. CK7 expression was correlated with epidemiologic data, p16ink4a positivity, and HPV status using SPSS.Results: CK7 expression was observed specifically and uniformly in the tonsillar crypt epithelium of normal tonsils and tumor specimens. There were 226 cases of oropharyngeal SCCs, with 70 demonstrating both HPV and p16 positivity. Of 216 cases evaluated for CK7, 106 demonstrated some positivity, whereas H-score > 60 was seen in 55 of these. CK7 H-score > 60 was significantly associated with tonsillar subsite and HPV and p16 positivity.Conclusions: An association between CK7 and HPV has been demonstrated. CK7-expressing tonsillar crypt cells potentially represent an oropharyngeal subsite susceptible to HPV-related SCC.Impact: Along with the cervix and anorectum, specific oropharyngeal expression of CK7 in a site predisposed to HPV-related tumors may suggest a role for CK7 in the pathogenesis of this subgroup of tumors. Further research is warranted to characterize the association between CK7 and HPV-related head and neck SCC. Cancer Epidemiol Biomarkers Prev; 26(5); 702-10. ©2017 AACR.

Prospective audit of a dedicated ear, nose and throat emergency department and 24-year comparison

BACKGROUND

The Royal Victoria Eye and Ear Hospital provides a specialised ear, nose and throat (ENT) Emergency department (ED) service open to patients from the entire country, operating from 9 am to 5 pm on weekdays. Recently, this has been under threat of closure.

AIMS

We analyse and determine the role of this ED in the current context and compare results to a previous study from June 1990.

METHODS

A prospective study over a 1-month period (March 2014) was conducted. A questionnaire was used, adapted from the study in 1990.

RESULTS

Comparative figures from June 1990 are in parentheses. During the study period, there were 945 (1167) consultations from 887 (779) patients. 57 % (45 %) were new patients and 43 % (55 %) were return patients. Repeat attendances were necessary in 54 (325) patients during this month. 56 % (35 %) were referred by their General Practitioner (GP), 38 % (52 %) self-referred, 2 % (8 %) by other hospitals and 4 % (5 %) from other sources. Diagnoses included otitis externa in 24 % (21 %), cerumen in 20 % (15 %), epistaxis in 6 % (9 %), Eustachian tube dysfunction in 12 %, foreign body removal in 4 % (5 %) and four new cases of head and neck cancer. Attendance numbers vary during the year but demand has risen over time.

CONCLUSIONS

A dedicated ED provides an important role for ENT in Ireland and offers valuable experience for trainees. The loss of such a department may lead to an overwhelming burden on services in other hospitals.

Systematic review and meta-analysis of wound drains after thyroid surgery

BACKGROUND

Drainage after routine thyroid and parathyroid surgery remains controversial. However, there is increasing evidence from a number of randomized clinical trials (RCTs) suggesting no benefit from the use of drains.

METHODS

A systematic review and meta-analysis was performed according to PRISMA guidelines. A literature search was carried out, and RCTs comparing the use of drains versus no drains in patients who underwent thyroid or parathyroid surgery were included. Trials including patients who underwent lateral neck dissection were excluded. Methodological quality was graded and data were extracted by independent reviewers. Risk ratio (RR) or mean difference (MD) with 95 per cent confidence interval (c.i.) was calculated and heterogeneity was assessed.

RESULTS

Twenty-five RCTs were included in the meta-analysis comprising 2939 patients. There was no significant difference between the two groups in rate of reoperation for neck haematoma (RR 1·90, 95 per cent c.i. 0·87 to 4·14), ultrasound-assessed fluid volume on day 1 after surgery (MD 2·30 (95 per cent c.i. -0·73 to 5·34) ml), wound collection requiring intervention (RR 0·64, 0·38 to 1·09) or not (RR 0·93, 0·66 to 1·30), transient voice change (RR 2·33, 0·91 to 5·96) and persistent recurrent laryngeal nerve palsy (RR 1·67, 0·22 to 12·51). Length of hospital stay was significantly greater in the drain group (MD 1·25 (0·83 to 1·68) days), as were wound infection rates (RR 2·53, 1·23 to 5·21) and pain score measure using a visual analogue scale from 1 to 10 on day 1 after surgery (MD 1·46 (0·67 to 2·26) units).

CONCLUSION

The results indicate that drain use after routine thyroid surgery does not confer a benefit to patients.

Proximal-type epithelioid sarcoma: case report of an unusual presentation

Epithelioid sarcoma, first described by Enzinger in 1970, classically presents in young adults and usually arises in the distal extremities. The proximal-type variant, first described in 1997 as a rare aggressive form of sarcoma, usually arises more proximally. It carries a higher mortality rate than classical limb epithelioid sarcoma and is often resistant to multimodal treatment. We report the case of a 27-year old male who had a delayed diagnosis of proximal-type epithelioid sarcoma of the forearm. This was originally thought to be a necrotising soft tissue infection and was unfortunately metastatic at the time of eventual diagnosis. The clinical and histopathological features of this challenging tumour are discussed and the relevant literature is reviewed.