Effect of prophylactic central neck dissection on the surgical outcomes in papillary thyroid cancer: experience in a single center

PURPOSE

Morbidity due to papillary thyroid carcinoma (PTC) is increased mostly due to lymph node (LN) metastases, which lead to reoperations and complications associated with these operations. The aim is to compare the outcomes of PTC having total thyroidectomy and prophylactic central lymph node dissection (TT + PCND) with patients having total thyroidectomy (TT) alone.

METHODS

This study is a retrospective cohort analysis of 358 PTC patients that were operated by a single surgeon in a single center. Data about the patients were extracted from the medical records.

RESULTS

Of the patient cohort, 258 patients had TT + PCND (42.5 ± 11.3 years) and 100 patients (41.2 ± 11.9 years) had only TT. Total number of LN extracted in the TT + PCND group was 8.1 ± 6.9. The mean number of metastatic LN were 2.2 ± 1.9. Percentage of patients that had RAI were less in the TT + PCND group compared to the TT group. Seven patients (2.7%) in the TT + PCND group and 19 (19.0%) in TT group had recurrent disease (p < 0.0001). Of the complications, only transient hypoparathyroidism was increased in TT + PCND group compared to TT group (26.7% vs 10%, p < 0.0001).

CONCLUSION

TT + PCND performed by an experienced surgeon seems to decrease the number of LN recurrences, and the need for reoperations.

Impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy

OBJECTIVES

To determine the impact of incidental parathyroidectomy and mediastinal-recurrent cellular and lymph-node dissection on parathyroid function after total thyroidectomy.

MATERIAL AND METHODS

A single-center retrospective study was conducted for a 5-year period in a university hospital center, including 605 patients undergoing total thyroidectomy, 52 of whom had mediastinal-recurrent cellular and lymph-node dissection.

ENDPOINTS

The main endpoint was intraoperative number of parathyroid glands as predictor of parathyroid hormone (PTH) level and postoperative hypocalcemia. The secondary endpoint was the correlation between associated mediastinal-recurrent cellular and lymph-node dissection and incidental parathyroidectomy and its impact on PTH level and calcemia in the immediate postoperative period and at 1 month.

RESULTS

161 patients (26.61%) showed hypocalcemia in the immediate postoperative period and 12 (1.98%) at 1 month. Mediastinal-recurrent cellular and lymph-node dissection increased incidental parathyroidectomy risk 4.6-fold. Mediastinal-recurrent cellular and lymph-node dissection was associated with a statistically "suggestive" decrease in day-1 calcemia (P=0.03), and no significant decrease at 1 month (P=0.52). Incidental parathyroidectomy (6.7% of cases with parathyroidectomy versus 1.3% without) did not significantly increase the rate of early hypocalcemia (P=0.28), but was associated with a "suggestive" worsening at 1 month (P=0.02).

CONCLUSION

Hypocalcemia after total thyroidectomy is a complex, probably multifactorial issue. Systematic parathyroid gland identification is not recommended due to the increased risk of gland lesion, mainly by devascularization. Incidental parathyroidectomy may induce hypocalcemia at 1 month postoperatively (statistically "suggestive" association).

A rare case of the recurrent surgery for cribriform-morular variant of papillary thyroid carcinoma

INTRODUCTION

The cribriform-morular variant of papillary thyroid carcinoma (CMV-PTC) is an uncommon subtype of PTC, and it is associated with familial adenomatous polyposis (FAP).

PRESENTATION OF CASE

We describe a 32-year-old female who presented recurrent CMV-PTC with FAP. Surgery performed after the recurrent disease resulted in left recurrent laryngeal nerve palsy due to formation of strong scar after initial operation. The histopathological examination revealed the recurrent CMV-PTC without thyroid capsular invasion in remnant thyroid tissue of berry ligament. In addition, the immunohistochemical analysis showed that β-Catenin was diffusely positive in both cytoplasm and nucleus in CMV-PTC tissue.

CONCLUSION

Total thyroidectomy in CMV-PTC with FAP should be performed at initial surgery due to high recurrence.

Bilateral hypocalcemic cataract after total thyroidectomy in a young woman: case report

BACKGROUND

Hypocalcemia is a derangement in serum calcium level due to a vast spectrum of disorders, but the most common cause is surgery, usually thyroid gland surgery. Symptoms of hypocalcemia can be due to increased neuromuscular excitation resulting in tetany, paresthesia or seizure. It can also be because of deposition of calcium in soft tissues producing reduced vision /cataract or calcification of basal ganglia. Cataract is the most common ocular symptom of hypocalcemia.

CASE REPORT

A twenty-six years old Ethiopian female patient presented with painless reduction of vision of both eyes. Five years prior to the reduction of vision she was diagnosed to have hypocalcemia. The serum calcium level was very low (3 mg/dl) due to damage to the parathyroid gland during total thyroidectomy for toxic goiter. She has been on supplemental calcium gluconate twice daily. She had typical bilateral symmetrical posterior sub capsular cataract with punctate iridescent opacities in the anterior and posterior cortex of the lens. Systemic examination revealed horizontal surgical scar on the anterior neck and positive Chvostek sign.

Total thyroidectomy for Graves' disease-what do our patients think? A qualitative cohort study to evaluate the surgical management of Graves' disease

INTRODUCTION

Total thyroidectomy for Grave's disease has been covered extensively in literature. There are established risks and side effects of the procedure, but in experienced hands, this is minimised. Studies show the physical complication rate of total thyroidectomy, but not a holistic view. The authors pose the question, "what do our patients really think"? Has there been a significant improvement in quality of life by doing this surgery?

METHODS

A cohort of patients who underwent total thyroidectomy for Graves' disease between the dates 2015-2018. A total of 95 patients were identified. The Glasgow Benefit Inventory (GBI) was used to ascertain patient's opinions on their surgery.

RESULTS

There were 54 responders, 46 female and 8 male. Average age was 41, with a range 20-81. Average GBI scores were 13.35 (SD 30.16). A general subset had an average score of 19.21 (SD = 32.59), a social subset average was 9.57 (SD = 25.61), and a physical subset was average -6.79 (SD = 37.40). Patients' feedback included positive and negative statements on their feelings surrounding pre-operative communication and post-operative side effects.

CONCLUSION

Overall, the GBI scores are positive, thereby showing an improvement in quality of life since having total thyroidectomy for Graves. Pre-operative communication was of paramount importance. It should be made clear to patients that they will require medication after surgery. The majority of patients stated they would prefer to know about "minor" post -operative side effects like weight gain or mood change post op. This highlights the importance of the consenting process- Montgomery Ruling-that clinicians explain the risks involved with surgery according to what the patient would deem a risk. In addition, they must be informed of the non-surgical options available, therefore, surgeons should be able to discuss risks and benefits of radio-iodine and anti-thyroid drugs too.

BRAFV600E mutation: a potential predictor of more than a Sistrunk's procedure in patients with thyroglossal duct cyst carcinoma and a normal thyroid gland

To assess the utility of mutational markers in determining the most appropriate initial surgery for patients with thyroglossal duct cyst carcinoma (TGDCCa) and a normal thyroid gland. Our sample comprised 15 patients with a diagnosis of TGDCCa and a thyroid gland histologically negative for any malignant involvement, who underwent surgery between the years 1994 and 2017. Clinical records were reviewed and tissue specimens were genetically tested for the presence of the most commonly encountered mutational markers in differentiated thyroid cancer: BRAF, N-RAS, and H-RAS. The primary outcome of interest was the correlation between mutational marker positivity and the T-stage of the primary tumor and its potential implication on therapeutic decision making. All 15 cases were papillary carcinomas with a mean tumor size of 17 mm (2-40 mm). According to the 7th edition of the American Joint Committee on Cancer TNM staging system, these represented: T₁ (n = 3), T₂ (n = 1), and T₃ (n = 11). Cancerous invasion of the pericystic soft tissue and/or hyoid bone was considered T3. BRAF^V600E was the only mutational marker identified (7 in 15 cases). All BRAF^V600E-positive lesions were T₃, necessitating radioactive iodine ablation (RIA) therapy, therefore, total thyroidectomy. The correlation between BRAF^V600E positivity and extracystic cancerous extension was statistically significant [1.0 (7/7) vs. 0.5 (4/8); p value = 0.0035]. BRAF^V600E positivity seems to be predictive of locally advanced disease mandating RIA therapy. Therefore, it could serve as a preoperative tool that predicts the need for total thyroidectomy, in addition to Sistrunk's procedure.

Correlation of Primary Tumour Size and Central Compartment Lymph Nodes Metastasis in Well Differentiated Thyroid Malignancies in a Tertiary Care Centre

Central compartment lymph nodes are the first to be involved in thyroid carcinoma and associated with higher chances of recurrence. (1) Recurrence and revision surgery can be associated with a high risk of vocal cord paralysis and hypocalcemia. (2) However, the need for central compartment lymph nodes dissection routinely in all cases of thyroid malignancies is controversial considering the risk to recurrent laryngeal nerve and parathyroids. (3) The aim of the study was to evaluate the incidence of central compartment lymph nodes metastasis in well differentiated thyroid malignancy and their correlation with size of the primary tumour along with incidence of postoperative hypocalcemia and recurrent laryngeal nerve injury after central compartment lymph node dissection. Observational study 30 patients diagnosed as well-differentiated thyroid carcinoma after fine needle aspiration cytology and planned for total thyroidectomy and central compartment lymph node dissection in the Department of ENT at a tertiary care hospital in Mysuru were studied. After surgery, histopathological examination (HPE) of thyroid and lymph node specimen was done. Postoperatively, all patients were evaluated for hypocalcemia and recurrent laryngeal nerve injury. The incidence of central compartment lymph node metastasis after HPE was 66.6%. 80% cases with tumor size ≤ 1 cm and 64% cases having tumor size > 1 cm showed central compartment lymph node involvement. Overall Incidence of transient Hypocalcaemia was 40%. No case of recurrent laryngeal nerve palsy was observed. In well-differentiated thyroid malignancies we found a high incidence of central compartment lymph node involvement which was even higher with primary tumour of smaller size (≤ 1 cm). We did not find any incidence of permanent hypocalcemia and recurrent laryngeal nerve injury. So based on our study we emphasize on elective central compartment lymph node clearance to avoid recurrence.

Clinical Treatment Efficacy of Total Thyroidectomy Combined with Radioactive Iodine on Treatment of Thyroid Cancer and Its Effect on the Quality of Life of Patients

BACKGROUND

To investigate the treatment efficacy of radioactive iodine therapy on patients after total thyroidectomy and its effect on the quality of life.

METHODS

A retrospective analysis of clinical data of 120 thyroid cancer patients admitted to Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China from February 2014 to February 2017 was performed. According to different treatment methods, they were divided into observation group of 62 cases and control group of 58 cases. Both groups were treated with total thyroidectomy. The control group was treated with anti-infection and prevention of complications after operation, the observation group with radioactive iodine therapy. Treatment efficacy, quality of life score, recurrent laryngeal nerve injury and postoperative survival rate were compared between the two groups.

RESULTS

The total effective rate of treatment in the test group was 98.39%, significantly higher than 72.41% in the control group, with a statistically significant difference (P<0.05). Compared with the control group, the fatigue score of the test group was lower, but the score in the area of emotion function and the overall health status score were higher, with a statistically significant difference (P<0.05). There was no significant difference in the recurrent laryngeal nerve injury between the two groups of patients. The postoperative survival rate of the test group of patients was 96.77%, significantly higher than 86.21% of the control group.

CONCLUSION

The effect of radioactive iodine therapy after total thyroidectomy is remarkable, which can significantly improve the clinical treatment efficacy and postoperative quality of life of patients, worthy of clinical application.

Total thyroidectomy vs completion thyroidectomy for thyroid nodules with indeterminate cytology/follicular proliferation: a single-centre experience

Background

Despite total thyroidectomy (TT) is the most practiced procedure for a preoperatively diagnosed neoplastic lesion, according to the ATA guidelines, many surgeons perform completion thyroidectomy (CT) after hemithyroidectomy for patients with preoperative follicular proliferation/indeterminate cytology who are diagnosed with malignancy. CT has a higher complication rate than the primary procedure. The primary endpoint of our study is to compare the morbidity rate after CT with that after primary TT in patients with follicular proliferation/indeterminate cytology.

Methods

We retrospectively reviewed 237 patients who underwent thyroid surgery from 2009 to 2018 at our institution. We recruited only patients with follicular proliferation/indeterminate cytology and excluded those undergoing lymphadenectomies and thyroidectomies for benign pathology and staged thyroidectomies after intraoperative documentation of a RLN lesion. One hundred eighty-six of these patients underwent TT, and fifty-one underwent CT for the detection of differentiated thyroid cancer at the histological exam.

Results

No differences were found in the total complication rates between the two groups (OR 0,76, 95% CI 0.35–1.65, P = 0.49). We did not find any significant differences in the subgroup analysis. In particular, no significant differences were identified for transient hypocalcaemia (OR 1.17, 95% CI 0.44–3.11; P = 0,74), permanent hypocalcaemia (OR 1.04, 95% CI 0.21–5.18; P = 0,95), transient unilateral recurrent laryngeal nerve palsy (OR 0.78, 95% CI 0.21–2.81; P = 0,16), permanent unilateral recurrent laryngeal nerve palsy (OR 1.48, 95% CI 0.28–7.85; P = 0,61), and haematoma (OR 1,84, 95% CI 0,16-20,71; P = 0,61).

Conclusions

CT following hemithyroidectomy can be performed with acceptable morbidity in patients with thyroid nodules with preoperative indeterminate cytology/follicular proliferation.

Correlation between iPTH Levels on the First Postoperative Day After Total Thyroidectomy and Permanent Hypoparathyroidism: Our Experience

Permanent hypoparathyroidism is the most common long-term complication after thyroidectomy. We evaluated whether iPTH concentrations on the first postoperative day may be a good predictor of this complication.

Patients undergoing thyroidectomy in our Unit between January 2017 and February 2018 who developed postsurgical hypoparathyroidism were analysed. According to iPTH values on the first postoperative day and on the basis of the detection threshold of the iPTH test used, patients were divided into 2 groups: Group A (iPTH < 6.3 pg/mL, undetectable), Group B (iPTH ≥ 6.3 pg/mL).

Seventy-five patients were included in this study: 64 in Group A and 11 in Group B. Permanent hypoparathyroidism occurred in 14 (21.88%) patients in Group A, while none developed this complication in Group B. When iPTH was < 6.3 pg/mL, the sensitivity for the prediction of permanent hypoparathyroidism was 100%, the specificity was 18.03%, the positive predictive value was 21.88% and the negative predictive value was 100%.

No patient with iPTH ≥ 6.3 pg/mL on the first postoperative day developed permanent hypoparathyroidism. On the other hand, iPTH concentrations < 6.3 pg/mL have not proved to be a strong predictor of this condition. However, this cut-off value can be useful to identify patients at risk of developing this complication.

Double Pyramidal Lobe of the Thyroid Gland a Rare Variation: Case Report

Knowledge of the variations of the pyramidal lobe of the thyroid is important for surgeons to perform complete resection of the functional thyroid tissue. Complete excision of the thyroid tissue surgery reduces the chances of recurrence in both the benign and the malignant diseases. It is important to remove all functioning thyroid tissue especially in the differentiated thyroid cancer so the postoperative radioiodine ablation is more effective and serum thyroglobulin acts as an efficient marker. We report a case of the double pyramidal lobe of thyroid gland in a woman of age 63 years with follicular thyroid cancer. Our literature search revealed only three documented cases of the double pyramidal lobe. Knowledge and recognition of such a rare variation is essential to perform safe and effective thyroid surgery.

The value of total thyroidectomy as the definitive treatment for Graves' disease: A single centre experience of 594 cases

PURPOSE

Thyroidectomy is the preferred approach as the definitive treatment for Graves' disease. The outcomes for total thyroidectomy in a large series of 594 patients, who were observed in the last decade, will be presented in this study.

METHODS

The study concerned a retrospective review of 594 patients, undergoing a total thyroidectomy for Graves' disease. The incidence of complications and outcomes on hyperthyroidism and correlated symptoms resolution were also evaluated.

RESULTS

The mean age of the patients was of 44.7 ± 12.7 years and 456 patients (76.7%) were females. The mean gland weight was 67.3 ± 10.8 g (range: 20-350 g) and, in 397 patients (66.8%), the gland weighed >40 g. The mean operative time was 125 ± 23.1 min (range: 65-212 min). Temporary and permanent hypocalcaemia developed in 241 (40.6%) and 3 patients (0.5%), respectively. Temporary and permanent recurrent laryngeal nerve palsy were recorded in 31 (5.2%) and 1 patients (0.16%) respectively. No patient developed a thyroid storm. On multivariate analysis, patient age ≤50 years (Odds ratio: 1; 95% Confidence Interval: 0.843-0.901) and thyroid weight >40 g (Odds ratio: 1; 95%, Confidence Interval: 0.852-0.974), were mainly associated with the occurrence of complications.

CONCLUSION

This high-volume surgeon experience demonstrates that total thyroidectomy is a safe and effective treatment for Graves' disease. It is associated with a very low incidence rate of post-operative complications, most of which are transitory; therefore, it offers a rapid and definitive control of hyperthyroidism and its related symptoms.

The role of prophylactic central compartment lymph node dissection in elderly patients with differentiated thyroid cancer: a multicentric study

BACKGROUND

Prophylactic central neck lymph-nodes dissection is still a topic of major debate in Literature. There is a lack of randomized controlled trials proving advantages in its application in terms of overall survival and local recurrence. Due to the recent rapid increase of elderly population, differentiated tumor carcinoma diagnosis increased in patients over 65 years old. The aim of this study was to compare recurrence rate, complications rate and histological features of tumors in elderly population.

METHODS

A retrospective study was carried out collecting data from 371 patients with differentiated thyroid cancer without clinical evidence of lymph-nodes involvement in three Italian referral centers from 2005 to 2015. All patients were aged ≥ 65 years and were divided in two groups based on the performed surgery (total thyroidectomy alone or associated with central lymph-nodes dissection). Moreover, patients were stratified according to the age between 65 and 74 years old and over 75 years old.

RESULTS

Total thyroidectomy alone was performed in 184 patients (group A) and total thyroidectomy with prophylactic central neck dissection was performed in 187 cases (group B). There was a statistically significant difference in complications between the groups in terms of neck hematoma (0.5% group A vs 3.7% group B), temporary hypoparathyroidism (11.4% group A vs 21.4% group B), and temporary unilateral recurrent nerve injury (1.5% group A vs 6.4% group B). Lymph nodes recurrence rate was 9.2% in group A and 8.5% in group B, with no statistically significant difference. There was a statistically significant difference in patients over 75 years old in terms of temporary hypoparathyroidism (24% group A vs 11% group B), permanent hypoparathyroidism (2,7% group A vs 0,3% group B) and recurrent nerve injury (9,5% group A vs 2% group B).

CONCLUSIONS

The role of prophylactic central neck dissection is still controversial, especially in elderly patients, and an aggressive surgical approach should be carefully evaluated. The Authors reported a similar low recurrence rate between total thyroidectomy and total thyroidectomy associated with prophylactic central neck dissection, with increased postoperative complications in the lymphadenectomy group and in patients over 75 years old, advocating a tailored surgical approach in elderly population.

Impact of the new guidelines of the American Thyroid Association on the treatment of the differentiated thyroid tumor in an Italian center with medium-high volume thyroid surgery

Background

The therapy for differentiated thyroid tumors is currently built upon two cornerstones: the stage of the disease and the new guidelines of the American Thyroid Association, jointly converging to lobohystmectomy for selected cases that meet certain criteria. The aim of the study was to relate these guidelines to the activity of an Italian center with a medium-high volume of thyroidectomies in a region with a high rate of endemic disease of the thyroid.

Methods

In order to conduct the analysis, the clinical records of the last 3 years, including 194 cases of total thyroidectomy and 3 lobohystmectomy, were taken into consideration. There were 46 cases of differentiated thyroid cancer (18 incidental tumors were found during thyroidectomies for benign diseases). Postoperative complications, patient characteristics and the stage of the tumor were assessed in relation to the new ATA guidelines.

Results

All patients underwent total thyroidectomy, with 2 of them also undergoing lymphadenectomy. The incidence of transient hypoparathyroidism was 19% with 1 case of permanent deficit. No cases of recurrent nerve injury were reported. Twenty-five out of the 28 patients with cancer preoperatively diagnosed were found with more nodules and in 15 of them the nodule had a diameter bigger than 1 cm. All the parameters suggested lobohystmectomy only for one case.

The treatment for the differentiated thyroid tumor is still widely discussed. Above all, differences between populations, screening methods and surveillance programs are still evident.

Conclusions

The ATA guidelines applied to our cases, even if limited, have shown limited applicability to our study, mainly due to the high incidence of multinodularity and the size of the nodule: typical characteristics of a region with a high rate of endemic thyroid pathology.

Follicular proliferation TIR3B: the role of total thyroidectomy vs lobectomy

BACKGROUND

TIR3B thyroid nodules are considered to be at risk of malignancy (15-30%) but guidelines recommend conservative surgery with lobectomy with primary diagnostic porpoise. Risk stratification mainly based on ultrasound, elastography and genetic mutations usually may influences the surgical approach.

METHODS

We retrospectively analyzed 52 cases of TIR3B underwent between 2015 and 2017 total thyroidectomy (TT) and lobectomy (L), focusing mainly on the observed rate of malignancy. Chi-squared test and Fisher's exact probability test were used for analysis, considering a P values less than 0.05 as significant.

RESULTS

Out of 52 patients 49 underwent TT and 3 L. In TT group a multinodular goiter was associated in 67.3% of patients. Malignancy rate was 81.6 and 33.3% respectively after TT and L (P 0.003). Multicentric and contralateral tumors were detected respectively in 36.7% and in 32.6% of patients underwent TT. No main post-operative complications were registered.

CONCLUSIONS

Ultrasound and elastography are useful to define within the TIR3B group those lesions at higher risk and therefore requiring a more radical approach. TT seems an appropriate approach to TIR3B lesions, especially in multinodular goiter, considering the incidence of malignancy with probably higher rate than previously reported.

Complications after reoperative thyroid surgery: retrospective evaluation of 152 consecutive cases

Reoperative thyroid surgery is an uncommon procedure that is indicated in recurrent benign or malignant disease. It is associated with a high complication rate, especially of hypoparathyroidism and recurrent nerve palsy. We retrospectively reviewed our series of patients on whom reoperative thyroid surgery was performed and we compared this group with patients who underwent primary thyroidectomies. From 2002 to 2015, 4572 thyroidectomies were performed at our institution; among these, 152 (3.3%) were for benign or malignant recurrent disease. We observed a higher rate of transient hypoparathyroidism in secondary vs primary surgery (56.6% vs 25.9%; p < 0.0001), of permanent hypoparathyroidism (10% vs 2.0%; p < 0.0001) and of transient recurrent nerve injury (4.6% vs 1.4%; p < 0.05). Reoperative thyroid surgery is a technical challenge with a high incidence of complications. Scarring, edema, and friability of the tissues together with distortion of the landmarks make reoperative surgery hazardous. Careful assessment of patient's risk factors, physical examination, and if necessary fine needle aspiration cytology are crucial for selecting the patients who should undergo reoperation. Research registry n. 2617 registered 5 June 2017 (retrospectively registered).

Diagnostic pitfalls and therapeutic outcomes of the macrofollicular variant of papillary thyroid carcinoma

Background

The macrofollicular variant of papillary thyroid cancer (MFVPTC) is a rare histological variant of papillary thyroid cancer (PTC), with only 71 cases reported through 2014. This study analyzed the clinical, preoperative thyroid ultrasonography (US), and fine needle aspiration cytology (FNAC) features; and therapeutic outcomes of 11 patients with MFVPTC.

Methods

The records of 393 patients with histologically diagnosed follicular variant of papillary thyroid carcinoma (FVPTC), including 11 with MFVPTC, were retrospectively reviewed. Preoperative thyroid US findings, clinical presentation, treatment outcomes, and survival rates were analyzed.

Result

Mean tumor size was significantly greater in patients with MFVPTC than that in those with FVPTC (4.2 ± 2.1 cm vs. 2.9 ± 1.7 cm; p = 0.016). No patient with MFVPTC had lymph node involvement, but one had a micrometastasis to the lung, which responded well to therapeutic radioiodine. All MFVPTC lesions were isoechoic on US. Eight nodules had calcifications and eight had irregular margins. FNAC showed that these tumors had low cellularity, absence or focal presence of enlarged clear nuclei, and subtle or focal nuclear features of PTC. Cells were, arranged in microfollicular pattern, with abundant colloid background. Multifocal PTCs were detected in the opposite lobe of two patients. All 11 patients with MFVPTC had excellent outcomes. No patient experienced recurrence, and survival rates were high.

Conclusions

Malignant US criteria combined with FNAC features have a low preoperative diagnostic rate for MFVPTC. Surgery is recommended for patients with thyroid nodules larger than 4 cm and those with subtle and focal atypical nuclei in FNAC.

Frequency of Hypocalcaemia following Total Thyroidectomy

Background & Objective

Patients who undergo Total thyroidectomy are at higher risk for postoperative hypocalcaemia, which can lead to significant short and long term morbidity. The aim of this study was to determine the frequency of postoperative hypocalcaemia undergoing Total thyroidectomy.

Methods

A total of 854 patients who underwent Total thyroidectomy and completion thyroidectomy between January 2003 to December 2016 at Endocrine Surgical unit, Jinnah Postgraduate Medical Centre, Karachi, were included in this retrospective study. Data were obtained for demographics, preoperative diagnosis, postoperative calcium levels, extent of surgery and final surgical pathology.

Results

A total of 854 patients underwent Total thyroidectomy. Of these 87.58% (n=748) were malignant and 12.41% (n=106) were benign. Among the malignant and benign patients, 47.3% (n=404) underwent Total thyroidectomy and 52.69% (n=450) underwent completion thyroidectomy. Overall incidence of transient hypocalcaemia was 7% (n=60) and that of permanent hypocalcaemia was 0.11% (n= 1).

Conclusion

Hypocalcaemia is one of major concern following total- thyroidectomy. Meticulous surgical techniques, identification and preservation of vascularity of parathyroid glands are essential in preventing postoperative hypocalcaemia following total thyroidectomy.

Papillary Carcinoma in Thyroglossal Cyst: an Unusual Case

Malignancy developing in thyroglossal cysts is very rare. Papillary carcinoma is the most common histopathological type of carcinoma encountered in thyroglossal cysts followed by squamous cell carcinoma. A 50-year-old male presented with a midline neck swelling. After ultrasonography and fine needle aspiration cytology, he underwent Sistrunk operation for removal of the thyroglossal cyst. The histopathology was reported as papillary carcinoma of the thyroid. So, he underwent total thyroidectomy, which showed foci of papillary microcarcinoma. Clinical awareness of this rare condition is essential for proper management. Possibility of malignancy arising in thyroglossal cysts should be considered in elderly patients.

Myxedema coma precipitated by diabetic ketoacidosis after total thyroidectomy: a case report

BACKGROUND

Myxedema coma is profound decompensated hypothyroidism usually precipitated by stressors, and its occurrence in association with total thyroidectomy or metabolic disorders, such as diabetic ketoacidosis, is unusual.

CASE PRESENTATION

A 43-year-old Asian man with history of total thyroidectomy who was scheduled for a second radioactive iodine therapy presented to our hospital with decreased mental status and hyperglycemia. He had a history of thyroid cancer but did not have diabetes mellitus. He was in a hypothermic state and had a Glasgow Coma Scale score of 10 out of 15 at presentation; arterial blood gas analysis revealed a state of metabolic acidosis and laboratory findings suggested hyperglycemia with glycosuria, ketoacidosis, and severe hypothyroidism. A thyroid function test showed thyroid-stimulating hormone of 34.126 uIU/mL, free thyroxine of 1.02 ng/dL, and triiodothyronine of 1.04 ng/mL. The glycated hemoglobin of this patient was checked due to hyperglycemia and the value of glycated hemoglobin was 16.5% which met the criteria for a diagnosis of diabetes. After treatment for myxedema with liothyronine 5 mcg two times per day and levothyroxine 175 mcg once daily via a nasogastric tube and diabetic ketoacidosis with intravenously administered fluid and insulin, his clinical condition rapidly improved including mental status, hyperglycemia, and acidosis. During the hospitalization, a workup for diabetes mellitus was performed and the results suggested that a diagnosis of type 2 diabetes mellitus would be appropriate.

CONCLUSIONS

This case demonstrated that diabetic ketoacidosis not only could be a potential contributor to myxedema coma but also mask typical clinical features, making diagnosis more difficult. Considering the possibility of an increasing number of potential patients with hypothyroidism developed after thyroidectomy, constant vigilance is required for a better clinical outcome, including early recognition and management in critical care in advance for unusual diabetic ketoacidosis which could precipitate decompensated hypothyroidism.

Change of surgical strategy for Graves' disease from subtotal thyroidectomy to total thyroidectomy: a single institutional experience

The extent of thyroidectomy in Graves' disease remains controversial. In our institution, long-term euthyroidism without thyroxin replacement therapy has been the aim, and it has long been the standard surgical procedure used to treat Graves' disease in many institutions, including our hospital. Based our several clinical studies, it was concluded that subtotal thyroidectomy is not suitable as a standard surgical procedure for the treatment of Graves' disease. In 2009, the surgical strategy for Graves' disease was changed from subtotal thyroidectomy to total thyroidectomy in our hospital. In this study, how surgical complications have changed after this modification was examined. The subjects were 1,476 patients with Graves' disease treated by thyroidectomy between 2006 and 2014. There were 1,119 females and 357 males with a median age of 39 years. A total of 660 patients underwent bilateral subtotal thyroidectomy (ST group), and 816 patients underwent total thyroidectomy (TT group). Both transient hypocalcemia and prolonged hypocalcemia were observed significantly more frequently in the TT group than in the ST group (p < 0.001). Total thyroidectomy was identified as risk factors for prolonged hypocalcemia on multivariate analysis. In conclusion, total thyroidectomy is a reliable and effective therapy for controlling hyperthyroidism in terms of controlling of hyperthyroidism. However, it should be noted that total thyroidectomy resulted in increased rate of prolonged hypocalcemia. Surgeons should try to reduce the surgical complication rate as much as possible.

Total thyroidectomy versus lobectomy for intermediate-risk papillary thyroid carcinoma: A single-institution matched-pair analysis

BACKGROUND

Total thyroidectomy (TT) is recommended by guidelines for intermediate-risk papillary thyroid carcinoma (PTC) but its survival advantage over lobectomy has not been proven. The aim of this study was to examine the association between the extent of surgery and the clinical outcome of patients with intermediate-risk PTC.

METHODS

Adult patients with PTC in the institutional database from 1996 to 2008 were retrospectively reviewed. Intermediate-risk patients were defined according to the 2015 American Thyroid Association (ATA) guidelines. Patients who underwent TT and patients who underwent lobectomy were then matched according to individual risk factors. Survival analysis was performed within the two paired groups, focusing on recurrence-free survival (RFS) and disease-specific survival (DSS) rates.

RESULTS

Among 4230 PTC patients, 1087 intermediate-risk patients were included, in total 341 pairs were matched based on sex, age, primary size, clinical nodes (cN), extrathyroidal extension (ETE), pathological lateral neck metastasis (pN1b) and lymph node ratio (LNR). For these paired cases, with a median follow-up of 125 months (46-192), the lobectomy and TT groups were similar with respect to both 10-year RFS rate (77.4% vs 80.2%, log rank = 0.244, p = 0.622) and DSS rate (97.2% vs 98.4%, log rank = 0.351, p = 0.554). When excluding pairs of cases (62 pairs) who received radioiodine ablation (RAI), survival results were also similar in lobectomy and TT groups with respect to 10-year RFS rate (81.2% vs 83.1%, log rank = 0.63, p = 0.42) and DSS rate (97.3% vs 98.1%, log rank = 0.95, p = 0.33).

CONCLUSIONS

For intermediate-risk PTC, no advantages of TT over lobectomy were found with respect to RFS rate or DSS rate.

The surgical choice for unilateral thyroid carcinoma in pediatrics: Lobectomy or total thyroidectomy?

BACKGROUND

Total thyroidectomy is no doubt the standard procedure for patients with bilateral thyroid carcinoma in pediatrics. However, for lesions confined in unilateral thyroid gland, lobectomy or radical total thyroidectomy is still controversial in pediatrics.

METHODS

Thirty-five cases of pediatric thyroid carcinoma which were confirmed by pathology were retrospectively analyzed in our hospital from 2005 to 2016. In 13 cases of unilateral lesions, 6 received lobectomy, while others underwent total thyroidectomy. Recurrence and complications were compared between 2 groups. Also, there were 20 cases of primary total thyroidectomy and 4 cases of supplementary resection of the residual gland. The short-term complications were compared.

RESULTS

There were no differences between groups of lobectomy and total thyroidectomy in size, extrathyroid extension, stage, cervical lymph nodes metastases, and distant metastases. They were the same in incidence of postoperative hypocalcemia, calcium supplement, recurrent laryngeal nerve damage, and recurrence rate and mortality, except that the length of stay in hospital was shorter in lobectomy group. Patients in supplementary resection were more likely to present the symptoms of postoperative hypocalcemia and hypokalemia, and it was difficult to identify the parathyroid gland during the operation by comparing with patients of primary total thyroidectomy.

CONCLUSIONS

Thyroid carcinoma in pediatrics is inclined to be multifocal, and even in a single focus, the volume is large. Total thyroidectomy does not bring more complications. In contrast, the morbidity increases in staged resection. Endocrine hormone supplement can satisfy the need for growth and development.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Intraoperative carbon nanoparticles mapping in secondary total thyroidectomy for recurrent thyroid nodules: Results of a 8-criterion case-match study (case control study)

BACKGROUND

The extent of total thyroidectomy in the management of multinodular goiter remains unclear. Compared to primary thyroidectomy, secondary total thyroidectomy is more difficult to perform and carries a significantly higher risk of postoperative complications such as recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism. In this study, we aimed to evaluate the efficacy and safety of intraoperative carbon nanoparticle (CN) mapping in patients undergoing secondary total thyroidectomy.

METHODS

We performed a case-matched analysis of a prospectively maintained database using 8 specific criteria to compare perioperative outcomes after primary total thyroidectomy to those after secondary total thyroidectomy with intraoperative CN mapping. The criteria included age, sex, operative procedure, RLN/parathyroid glands (PGs) exploration, preoperative vocal cord calcium abnormalities, and pathological results. Thirty-five patients underwent secondary total thyroidectomy with intraoperative CN mapping due to recurrent thyroid nodules or development of nodules suspicious for malignancy after subtotal thyroidectomy. Fifty exact matches for all 8 criteria were identified from the database in our previous study, which included records of 3078 primary thyroidectomies without CNs. Perioperative outcomes, surgical technique, and complications were analyzed.

RESULTS

The RLNs were successfully identified in all 35 patients. Among three patients that experienced slight hoarseness, one had an RLN end-to-end anastomosis with subsequent improvement in the during the 12-month follow-up period. Two patients experienced changes in vocal tone, but recovered after several months. Two patients underwent parathyroid auto-transplantations, and subsequently presented with transient hypocalcaemia. Their symptoms gradually remitted within one year. Except for mean operation time, there were no statistically significant differences in complications between the primary total thyroidectomies and the secondary total thyroidectomy with CNs.

CONCLUSIONS

Intraoperative CN mapping, expert knowledge of the jugular anatomy, and standardized resection procedures can minimize the incidence of complications such as RLN palsy and hypoparathyroidism after secondary total thyroidectomy.

Negative remnant 99mTc-pertechnetate uptake predicts excellent response to radioactive iodine therapy in low- to intermediate-risk differentiated thyroid cancer patients who have undergone total thyroidectomy

OBJECTIVE

Negative ^99mTc-pertechnetate uptake of the thyroid bed indicates the absence or a small volume of remnant thyroid tissue (RTT) after total thyroidectomy (TT). The aim of this study is to evaluate the predictive value of negative ^99mTc-pertechnetate scintigraphy for excellent response (ER) to radioactive iodine therapy (RIT) in low- to intermediate-risk differentiated thyroid cancer (DTC) patients.

PATIENTS

One-hundred and eighty-nine low- to intermediate-risk DTC patients who underwent TT, RIT with a single dose of 30 mCi and suppressive therapy with thyroid-stimulating hormone (TSH) from July 2015 to February 2016 in our hospital were retrospectively evaluated. ^99mTc-pertechnetate thyroid scintigraphy was performed just before RIT and images were reported dichotomously as negative or positive. The response of patients was assessed for 23.2 ± 3.8 months after RIT and dichotomized as excellent response (ER) or non-excellent response (NER). ^99mTc-pertechnetate uptake, age at diagnosis, gender, multifocality, T stage, N stage, preablative stimulated thyroglobulin (ps-Tg), and TSH were explored as potential predictors for ER.

RESULTS

80.68% (71/88) of patients with negative ^99mTc-pertechnetate uptake achieved ER. When patients were evaluated according to different ps-Tg levels, we found that 94.83% (55/58) of patients with ps-Tg < 1 ng/ml and negative ^99mTc-pertechnetate uptake achieved ER. Multivariate Cox regression analysis revealed that ps-Tg (P = 0.0001) and ^99mTc-pertechnetate uptake (P = 0.0473) were independent predictors for ER.

CONCLUSIONS

In addition to ps-Tg, negative ^99mTc-pertechnetate uptake is also a significant independent predictor for an excellent response in low- to intermediate-risk patients. It may be possible to omit RIT in patients with ps-Tg < 1 ng/ml and concurrent negative ^99mTc-pertechnetate uptake.