[Update of the S2k guidelines : Surgical treatment of benign thyroid diseases]

[Individualization of treatment in sporadic and hereditary medullary thyroid cancer]

BACKGROUND

Routine preoperative assessment of the tumor marker calcitonin for medullary thyroid cancer (MTC) and the generally improved diagnostics with high-resolution ultrasound, elastography and Doppler function as well as functional imaging, enable the earlier detection of organ-limited, non-metastasized MTC. Thereby, a new treatment option arises for surgical de-escalation in sporadic MTC, moving from routine thyroidectomy with bilateral central lymph node dissection towards unilateral thyroidectomy with ipsilateral central lymph node dissection.

MATERIAL AND METHODS

A search was carried out in PubMed for surgical approaches and selection of publications with results from limited resection in sporadic MTC.

RESULTS

In selected patient cohorts limited resection surgery can achieve adequate oncological results but requires long-term follow-up.

DISCUSSION

When sporadic unifocal primary tumors are identified and intraoperative frozen section pathological investigation is consistently employed for assessing the grade of desmoplasia and breach of the tumor capsule, the extent of resection can be intraoperatively adapted. Pivotal prerequisites for this personalized concept include consideration of preoperative clinical criteria and intraoperative surgical assessment in conjunction with the intraoperative frozen section examination in order to achieve an adequate oncological tumor resection and a biochemical cure.

Thyroid diseases in children and adolescents requiring surgical treatment-indications, techniques, results, and complications based on 10 years of the single center's own experience

Introduction

Although thyroid abnormalities are observed less frequently in children than in adults, the increased incidence of thyroid cancer makes it mandatory for all pediatric surgeons to be knowledgeable about the disorders of this gland. Thyroid abnormalities can be associated with hyperthyroidism or hypothyroidism and euthyroidism and/or symmetric or asymmetric enlargement of the gland.

Aim

The present study was undertaken to retrospectively analyze the indications, surgical techniques used, results obtained, and complications found in the surgical treatment of thyroid diseases in children and adolescents in a surgical center for the macro-region of western Poland.

Methods

The data of 148 patients undergoing total or partial thyroidectomy between 2013 and 2022 were analyzed from the medical records of the Department of Pediatric Surgery, Traumatology, and Urology of the Medical University of Poznan, Poland.

Results

A total of 95 children underwent subtotal thyroidectomy and 64 underwent total thyroidectomy, of which the procedure was widened to include prophylactic removal of neck lymph nodes in 45 patients. There were 113 girls (76%) in the analyzed group, and the average age of the patients at the time of surgical treatment was 15 years. The average time from the diagnosis of thyroid disease to surgery was 4 months, ranging from 2 weeks to 3 years. Of the 64 patients undergoing total thyroid resection, 35 (54.69%) were diagnosed with thyroid cancer.

Conclusions

Collaboration within a multidisciplinary team ensures optimal surgical outcomes in children and adolescents with thyroid disease. With extreme caution, thyroid removal is a safe procedure with few complications, but the experience of the surgeon performing thyroid surgery in children remains crucial. Despite the absence of such a diagnosis in the first fine-needle aspiration biopsy, the high percentage of thyroid carcinomas in the analyzed group may be because the initial biopsy was performed in a less experienced center, also in terms of histopathological laboratory. Hence, we point out the necessity of performing a repeat fine-needle aspiration biopsy (according to the Bethesda classification) in a more experienced center before the final decision of thyroidectomy.

Hypoparathyroidism - management, information needs, and impact on daily living from the patients' perspective: results from a population-based survey

PURPOSE

Hypoparathyriodism (hypoPT) is a rare endocrine disorder. It is not known how hypoPT is managed in Germany or whether patients have unmet information needs or impairments in their daily living.

METHODS

HypoPT patients at a minimum of 6 months' post-diagnosis were invited to participate in an online survey through their treating physician or through patient organizations. An extensive questionnaire, which was developed and pilot-tested with hypoPT patients, was administered.

RESULTS

A total of 264 patients with a mean age of 54.5 years (SD: 13.3), 85.2% female and 92% with postsurgical hypoPT, participated in the study. In total, 74% of the patients reported regular monitoring of serum calcium at least every 6 months, with lower control frequencies for phosphate (47%), magnesium (36%), creatinine (54%), and parathyroid hormone (50%), and 24-h urine calcium excretion (36%) on a yearly basis. Information on symptoms of hypo- and hypercalcemia was available in 72 and 45% of the patients. Information needs were related to the disease and its treatment as well as to nutrition, physical activities/sports, and support opportunities. Statistically significant differences for all information needs in association with symptom burden were observed. Hospitalization for hypocalcemia was reported by 32%, nutritional impairments (38%) or impact on work ability (52%) was available among patients with hypoPT.

CONCLUSION

HypoPT patients experience impairments in daily living and report unmet information needs. Patient and physician education regarding hypoPT is one of the key concepts for improving the management of patients with hypoPT.

Update on Calcitonin Screening for Medullary Thyroid Carcinoma and the Results of a Retrospective Analysis of 12,984 Patients with Thyroid Nodules

BACKGROUND

We provide an update on calcitonin (Ctn) screening for the early detection of medullary thyroid carcinoma (MTC) and present the results of a large single-center analysis evaluating sex-specific cut-off-levels and long-term courses.

METHODS

A total of 12,984 consecutive adult patients (20.1% male and 79.9% female) with thyroid nodules who had undergone routine Ctn measurement were retrospectively analyzed. Patients with confirmed suspicious Ctn values were referred for surgery.

RESULTS

Ctn measurements were elevated in 207 (1.6%) patients, with values below twice the sex-specific reference limit in 82% of these cases. Further clarification was possible in 124/207 cases, of which MTC could be ruled out in 108 cases. Histopathological assessment confirmed MTC in 16/12,984 patients.

CONCLUSIONS

Our extrapolated MTC prevalence of 0.14% is significantly lower than that described in early international screening studies. The stimulation test can usually be dispensable when using a decision-making concept based on sex-specific basal Ctn cut-off values. Ctn screening is recommended even in patients with very small thyroid nodules. High quality standards in pre-analytics, laboratory measurements, and the interpretation of data must be ensured, as well as close interdisciplinary cooperation between medical disciplines.

Accessing the influence of 99mTc-Sesta-MIBI-positive thyroid nodules on preoperative localisation studies in patients with primary hyperparathyroidism

Purpose

Curative treatment for primary hyperparathyroidism (PHPT) is parathyroidectomy (PTX) with removal of the hyperfunctioning gland(s). In an endemic goitre region, 35–78% of PHPT patients show concomitant thyroid disease. This study aimed to evaluate if ^99mTc-sestamibi (MIBI)-positive thyroid nodules decrease sensitivity in regard to localising the hyperfunctioning parathyroid gland(s) in PHPT patients.

Methods

Within 5 years, 497 consecutive patients with biochemically proven PHPT were included in this study. The data was analysed retrospectively.

Results

In total, 198 patients underwent PTX with thyroid surgery and 299 patients underwent sole PTX. Sensitivity of MIBI scan for PTX with and without thyroid surgery was 72.1% and 73.6%, respectively. A statistically significant difference in sensitivity of ultrasound for PTX with and without thyroid surgery (57.0% and 70.9%, respectively) was observed (p = 0.029). Thyroid nodule histology did not have a significant effect on the MIBI scan. Unilateral neck exploration (UNE) was performed in 110 patients and bilateral neck exploration (BNE) in 177 patients. The probability of surgical conversion from UNE to BNE due to incorrect localisation was 1.733 times higher in patients with thyroid nodules.

Conclusions

Concomitant benign thyroid nodules did not influence MIBI sensitivity. No correlation between thyroid carcinoma and MIBI uptake was determined. However, MIBI detection of thyroid malignancy is important in patients initially being considered for minimal invasive parathyroidectomy. Sensitivity and positive predictive value of ultrasound were significantly lower in patients with thyroid nodules. The probability of conversion from UNE to BNE due to incorrect localisation was 1.733 times higher in patients with thyroid nodules.

[Medicolegal aspects of primary and renal hyperparathyroidism]

BACKGROUND

Compared with malpractice claims in thyroid surgery, expert medico-legal reviews of surgery performed for hyperparathyroidism (HPT) that aim to prove or rebut surgical malpractice are rare. The aim of this analysis was to describe typical risk patterns for possible treatment errors and to generate recommendations for avoiding these treatment errors.

MATERIAL AND METHODS

A total of 12 surgical expert medico-legal reviews, which were carried out by order of 9 arbitration boards and 3 courts between 1997 and 2020 were evaluated.

RESULTS

If the indications for surgical treatment of hyperparathyroidism were present, the failure to identify a parathyroid adenoma or hyperplastic parathyroid glands was in the majority of cases not rated as a surgical treatment error, especially in atypical localizations. Unilateral recurrent laryngeal nerve palsy and postoperative bleeding cannot always be prevented, despite maximum diligence. In contrast, bilateral recurrent laryngeal nerve palsy can be prevented when intraoperative neuromonitoring is correctly applied. A lack of patient information regarding postoperatively persistent HPT, postoperative hypoparathyroidism following the removal of inconspicuous parathyroid glands and nonindicated lobectomy or total thyroidectomy, mostly performed under the assumption of an intrathyroid parathyroid adenoma, represented avoidable malpractice issues.

CONCLUSION

Advanced knowledge of the pathophysiology of the disease and the anatomy of the parathyroid glands as well as the establishment of intraoperative and perioperative standards can prospectively greatly reduce avoidable errors in the surgical treatment and postoperative care of HPT.

[Endocrine and neuroendocrine tumors]

Endokrine Tumoren und hier im Speziellen neuroendokrine Neoplasien des Gastrointestinaltraktes (GEP-NETs), Phäochromozytome (PCs), Paragangliome (PGL) und Schilddrüsentumoren sind Paradebeispiele für die Bedeutung von Molekularpathologie und Molekularbiologie für Diagnostik, Klassifikation und letztendlich auch die (chirurgische) Therapie dieser Erkrankungen. Bei GEP-NETs erfolgt das Grading anhand des Ki-67-Index. Dieser bestimmt die Art der molekularen Bildgebung (DOTA [1,4,7,10-Tetraazacyclododecan‑1,4,7,10-tetraessigsäure]/DOPA [3,4-Dihydroxyphenylalanin]/FDG[Fluordesoxyglukose]-PET[Positronenemissionstomographie]/CT [Computertomographie]), die mögliche Therapie (chirurgisch und/oder Radiopeptidtherapie), antiproliferative und symptomkontrollierende Therapie mit Somatostatinanaloga und letztendlich auch die Prognose. PC/PGL können hereditär auftreten (MEN2A [multiple endokrine Neoplasie Typ 2A], VHL [Von-Hippel-Lindau-Tumorsuppressor], NF1 [Neurofibromatose Typ 1], SDH[Succinat-Dehydrogenase]-Mutationen), was die chirurgische Therapie und die präoperative Medikation maßgeblich beeinflusst. Die molekulare Bildgebung hat einen hohen Stellenwert und kann bei grenzwertiger Biochemie wegweisend sein. Auch Nebennierenrindenkarzinome können genetisch determiniert sein. Bei Schilddrüsentumoren ist v. a. die Pathologie der C‑Zelle (C-Zell-Hyperplasie, medulläres Schilddrüsenkarzinom) hervorzuheben. Bei hereditärer Erkrankung (FMTC [familiäres medulläres Schilddrüsenkarzinom], MEN[multiple endokrine Neoplasie]2) ist häufig eine frühe prophylaktische Operation notwendig und verhindert das Auftreten von fortgeschrittenen Karzinomen. Aber auch die Bestimmung des Resektionsausmaßes bei follikulären Läsionen bzw. die Unterscheidung zwischen „non-invasive follicular thyroid neoplasm with papillary-like nuclear features“ (NIFTPs) und follikulären Varianten des papillären Schilddrüsenkarzinoms kann mithilfe spezifischer Marker erfolgen. Insgesamt hat die Molekularpathologie eine zunehmende Bedeutung bei diesen Entitäten und ist auch Inhalt laufender Forschungsprojekte.

Continuous Intraoperative Recurrent Laryngeal Nerve Monitoring: Techniques, Applications, and Controversies

Purpose of Review

Purpose of the present review is to illustrate the current state of the art concerning continuous intraoperative recurrent laryngeal nerve monitoring (cIONM) for thyroid surgery.

Recent Findings

cIONM potentially leads to an improved postoperative vocal cord palsy rate, compared to the intermittent technique. There are currently two main approaches for cIONM: either conventional cIONM based on vagal nerve stimulation or experimental methods, which do not require the positioning of a vagal nerve electrode. One of these methods is the recently described technique “LAR-cIONM,” which utilizes the laryngeal adductor reflex.

Summary

cIONM represents an advancement of intermittent nerve monitoring, which allows for an immediate reaction to signal changes. Threshold values and guidelines to prevent recurrent laryngeal nerve palsy were validated for the direct stimulation of the vagal nerve and require verification for alterative cIONM methods, including LAR-cIONM.

Perioperative diagnostics of patients referred for radioiodine therapy of differentiated thyroid carcinoma: referral center experience in an iodine-insufficient country

PURPOSE

The interdisciplinary "Martinique-Principles" of four international professional societies concerned with the patient management of differentiated thyroid cancer (DTC) patients were agreed upon. Differences in perioperative diagnostics can lead to differences in clinical decision founding regarding the treatment of thyroid carcinoma. Our aim was to analyze the perioperative diagnostics of patients referred for postoperative I-131 therapy of DTC.

METHODS

We retrospectively examined the data of 142 patients who were referred to our center for the first course of postsurgical I-131 therapy. We extracted data on perioperative diagnostics.

RESULTS

Fine-needle biopsy (FNB) was performed in 27/142 patients. In 17 patients, FNB yielded findings suspicious of malignancy, in 3 patients a follicular lesion was reported. An intraoperative frozen section analysis was performed in 79/142 patients. 5/63 patients showed already a cytologically proven malignancy. In 10/79 patients, the frozen section had a nonmalignant result, although DTC was found on final assessment. In 2/79 patients, frozen section analysis was indecisive, although the final report confirmed DTC. In the remaining 67 patients, frozen section yielded DTC.

CONCLUSIONS

There is room for improvement in perioperative diagnostics surrounding thyroid surgery, currently many procedures are performed without adequate information on potential presence of thyroid cancer. More frequent use of FNB might be able to decrease the number of unnecessary thyroid surgeries, increased use of frozen section might decrease the number of second operations and might contribute to less discordance between experts in the field of DTC treatment.

Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK)

BACKGROUND AND AIMS

The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK).

METHODS

Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF).

RESULTS

During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT.

CONCLUSION

Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.

Targeted use of intraoperative frozen-section analysis lowers the frequency of completion thyroidectomy

BACKGROUND

The impact of intraoperative frozen section (iFS) analysis on the frequency of completion thyroidectomy for the management of thyroid carcinoma is controversial. Although specialized endocrine centres have published their respective results, there are insufficient data from primary and secondary healthcare levels. The aim of this study was to analyse the utility of iFS analysis.

METHODS

In the Prospective Evaluation Study Thyroid Surgery (PETS) 2 study, 22 011 operations for benign and malignant thyroid disease were registered prospectively in 68 European hospitals from 1 July 2010 to 31 December 2012. Group 1 consisted of 569 patients from University Medical Centre (UMC) Mainz, and group 2 comprised 21 442 patients from other PETS 2 participating hospitals. UMC Mainz exercised targeted but liberal use of iFS analysis for suspected malignant nodules. iFS analysis was compared with standard histological examination regarding the correct distinction between benign and malignant disease. The percentage of completion thyroidectomies was assessed for the participating hospitals.

RESULTS

iFS analysis was performed in 35.70 per cent of patients in group 1 versus 21.80 per cent of those in group 2 (risk ratio (RR) 1.6, 95 per cent c.i. 1.5 to 1.8; P < 0.001). Sensitivity of iFS analysis was 75.0 per cent in group 1 versus 63.50 per cent in group 2 (RR 1.2, 1.2 to 1.3; P = 0.040). Completion surgery was necessary in 8.10 per cent of patients in group 1 versus 20.8 per cent of those in group 2 (RR 0.4, 0.2 to 0.7; P = 0.001).

CONCLUSION

iFS analysis is a useful tool in determining the appropriate surgical management of thyroid disease. Targeted use of iFS was associated with a significantly higher sensitivity for the detection of malignancy, and with a significantly reduced necessity for completion surgery.

Quality of life and surgical outcome of ABBA versus EndoCATS endoscopic thyroid surgery: a single center experience

Background

Thyroid surgery is often performed, especially in young female patients. As patient satisfaction become more and more important, different extra-cervical “remote” approaches have evolved to avoid visible scars in the neck for better cosmetic outcome. The most common remote approaches are the transaxillary and retroauricular. Aim of this work is to compare Endoscopic Cephalic Access Thyroid Surgery (EndoCATS) and axillo-bilateral-breast approach (ABBA) to standard open procedures regarding perioperative outcome and in addition to control cohorts regarding quality of life (QoL) and patient satisfaction.

Methods

In a single center, 59 EndoCATS und 52 ABBA procedures were included out of a 2 years period and compared to 225 open procedures using propensity-score matching. For the endoscopic procedures, cosmetic outcome, patient satisfaction and QoL (SF-12 questionnaire) were examined in prospective follow-up. For QoL a German standard cohort and non-surgically patients with thyroid disease were used as controls.

Result

The overall perioperative outcome was similar for all endoscopic compared to open thyroid surgeries. Surgical time was longer for endoscopic procedures. There were no cases of permanent hypoparathyroidism and no significant differences regarding temporary or permanent recurrent laryngeal nerve (RLN) palsies between open and ABBA or EndoCATS procedures (χ²; p = 0.893 and 0.840). For ABBA and EndoCATS, 89.6% and 94.2% of patients were satisfied with the surgical procedure. Regarding QoL, there was an overall significant difference in distribution for physical, but not for mental health between groups (p < 0.001 and 0.658). Both endoscopic groups performed slightly worse regarding physical health, but without significant difference between the individual groups in post hoc multiple comparison.

Conclusion

Endoscopic thyroid surgery is safe with comparable perioperative outcome in experienced high-volume centers. Patient satisfaction and cosmetic results are excellent; QoL is impaired in surgical patients, as they perform slightly worse compared to German standard cohort and non-surgical patients.

Short-Term Outcomes of Surgery for Graves' Disease in Germany

BACKGROUND

Surgical treatment of Graves' disease (GD) has a potentially increased incidence of postoperative hypoparathyroidism, recurrent laryngeal nerve palsy (RLNP) and bleeding. The aim of this study was to evaluate the current extent of surgery for the treatment of GD and its safety as a short-term outcome.

METHODS

Patients who underwent thyroid resection for GD were identified from the prospective StuDoQ/Thyroid registry. Patient data were retrospectively analyzed regarding demographics, surgical procedures and perioperative outcomes. Statistics were performed with Student's t-test or Fisher's exact test and multivariate Cox regression analysis. The level of statistical significance was set at p < 0.05.

RESULTS

A total of 1808 patients with GD with a median age of 44 (range 14-85) years were enrolled in a 25-month period by 78 departments, of which 35.7% (n = 645) had an endocrine orbitopathy and 0.1% (n = 6) had thyrotoxic crisis. Conventional open surgery was used in 98.6% of cases and minimally invasive or remote-access approaches were used in 1.4%. Total thyroidectomy was performed in 93.4% of cases (n = 1688). Intraoperative neuromonitoring (IONM) was used in 98.9% (n = 1789) of procedures. In 98.3% (n = 1777) at least one parathyroid gland was visualized and in 20.7% (n = 375) parathyroids were autografted. The rates of unilateral and bilateral transient RLNP were 3.9% (n = 134/3429 nerves at risk) and 0.1% (n = 4/3429 NAR). The rates of transient RLNP tended to be higher when intermittent IONM was used compared to continuous IONM (4.1% vs. 3.4%, p < 0.059). The rate of transient postoperative hypoparathyroidism was overall 29% (n = 525/1808). Multivariate analysis revealed fewer than 300 thyroid resections and fewer than 15 thyroid resections for GD per year, male sex, BMI > 30, autotransplantation of parathyroid glands and previous bilateral thyroid surgery as independent risk factors for postoperative temporary hypoparathyroidism. Reoperations for bleeding (1.3%) were rare.

CONCLUSION

Total thyroidectomy with IONM is safe and currently the most common surgical therapy for GD in Germany. Postoperative hypoparathyroidism is the major complication which should be focused on.

[Nodular goiter]

The indications for surgery of benign goiter should be balanced and professional as the prevalence of benign nodular goiter in Germany is high and not all goiters must be surgically treated. Thyroid nodules are detected in up to 76% of healthy people using modern high-resolution ultrasound (US) and only a few of these nodules are malignant or symptomatic. Even today a thorough medical history, detailed examination of the neck region, a qualified US of the thyroid gland, a 99m-technetium scintigraphy and fine needle aspiration help to select patients who will benefit from thyroid surgery. In the last 10 years several thyroid imaging reporting and data systems (TI-RADS) classifications have been introduced. The TI-RADS classification is a standardized assessment of thyroid nodules and risk stratification system in thyroid US which helps to select those nodules with a high risk of cancer. Asymptomatic euthyroid nodular goiter without any suspicion of malignancy and scintigraphically cold thyroid nodules without any other evidence of malignancy are not indications for thyroid surgery. The decision to operate should be made on an interdisciplinary basis in conformity with the relevant guidelines and exhaustion of diagnostic tools.

Effect of intraoperative nerve monitoring on postoperative vocal cord palsy rates after thyroidectomy: European multicentre registry-based study

Background

Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) predicts the risk of vocal cord palsy (VCP). IONM can be used to adapt the surgical strategy in order to prevent bilateral VCP and associated morbidity. Controversial results have been reported in the literature for the effect of IONM on rates of VCP, and large multicentre studies are required for elucidation.

Methods

Patients undergoing first‐time thyroidectomy for benign thyroid disease between May 2015 and January 2019, documented prospectively in the European registry EUROCRINE®, were included in a cohort study. The influence of IONM and other factors on the development of postoperative VCP was analysed using multivariable regression analysis.

Results

Of 4598 operations from 82 hospitals, 3542 (77·0 per cent) were performed in female patients. IONM was used in 4182 (91·0 per cent) of 4598 operations, independent of hospital volume. Postoperative VCP was diagnosed in 50 (1·1 per cent) of the 4598 patients. The use of IONM was associated with a lower risk of postoperative VCP in multivariable analysis (odds ratio (OR) 0·34, 95 per cent c.i. 0·16 to 0·73). Damage to the RLN noted during surgery (OR 24·77, 12·91 to 48·07) and thyroiditis (OR 2·03, 1·10 to 3·76) were associated with an increased risk of VCP. Higher hospital volume correlated with a lower rate of VCP (OR 0·05, 0·01 to 0·13).

Conclusion

Use of IONM was associated with a low rate of postoperative VCP.

Thyroid surgery in children and young adults: potential overtreatment and complications

Purpose

Thyroid nodules in the pediatric population are more frequently associated with malignant thyroid disease than in adult cohorts. Yet, there is a potential risk of surgical overtreatment. With this single center study, an analysis of potential overtreatment for suspected malignant thyroid disease in children and young adults was aimed for.

Methods

In a period from 2005 to 2018, 155 thyroid operations in children and young adults performed at the University Medical Center Mainz, Germany, were analyzed (patient age 3–20 years, 117 female). Cases were categorized for preoperative diagnosis: non-malignant (group I, n = 45) and malignant thyroid disease (group II, n = 110). Postoperative parameters (histology, complication rates) were assessed and compared between groups.

Results

91.1% of group I were histologically benign. 44.5% of group II harbored malignancy. Permanent hypoparathyroidism was documented in group I (2.7%) and in group II (1.4%, p = 1.000). Wound infections were absent in group I but observed in group II (0.9%, p = 1.000). Transient vocal cord palsy was recorded only in group I (2.3%, 2/85 vs. 0/177 nerves at risk, p = 0.104). Permanent vocal cord palsies were absent.

Conclusion

Preoperative diagnoses were correct in over 90% of group I and in nearly 45% of group II. The high proportion of carcinomas in group II ruled out the issue of potential overtreatment. The risk of severe postoperative complications was equally low in both patient groups.

Electronic supplementary material

The online version of this article (10.1007/s00423-020-01896-x) contains supplementary material, which is available to authorized users.

[Modern thyroid surgery - the surgeon's endocrine-surgical understanding and his responsibility for the extent of surgery and complication rate]

Die hohe Qualität der Schilddrüsenchirurgie impliziert ein endokrin-chirurgisches Verständnis des Operateurs mit dem Ziel einer bestmöglichen Ergebnisqualität. Das beinhaltet ein befundadäquates Resektionsausmaß und eine möglichst niedrige Komplikationsrate. Der Chirurg sollte frühzeitig in die Operationsindikation eingebunden sein und auch selbst die Diagnostik, speziell den Schilddrüsen- und Halslymphknotenultraschall, sowie die Interpretation der Schnittbild- und nuklearmedizinischen Verfahren beherrschen. Im Besonderen sollte er über zeitgemäße Radikalitätsprinzipien in der Chirurgie Bescheid wissen.

Bei der gutartigen Struma ist eine individualisierte Operationsstrategie anzuwenden: Solitärknoten können auch einer gewebeschonenden Knotenresektion unterzogen werden. Bei multinodulärer Knotenstruma ist nicht zwingend eine totale Thyreoidektomie notwendig, die Vermeidung eines permanenten Hypoparathyreoidismus hat Priorität. Bei Rezidivstrumen ist oft die einseitige Operation des dominanten Befundes zu bevorzugen. Auch besteht zunehmend der Trend, die Indikation zur Entfernung der Schilddrüsenlappen seitengetrennt zu stellen. Die Basedow Struma erfordert eine Thyreoidektomie. Auch die hypertrophe Thyreoiditis Hashimoto kann eine Operationsindikation darstellen.

Die Radikalitätsprinzipien bei maligner Struma haben sich ebenfalls deutlich gewandelt als auch die strenge Indikation zur Radiojodtherapie. Das gilt speziell für papilläre Mikrokarzinome und minimal invasive follikuläre Tumortypen. Selbst bei medullären Schilddrüsenkarzinom stehen die Radikalitätsprinzipien im Hinblick auf synchrone oder metachrone laterale Halsdissektion in Diskussion.

Der Hypoparathyreoidismus stellt derzeit das Hauptproblem in der radikalen Schilddrüsenchirurgie dar. Recurrensparese und Nachblutung sind durch die subtile Operationstechnik selten geworden. Spezielle extrazervikale Operationszugänge sind nach wie vor in der Erprobungsphase und unter strengen Studienbestimmungen nur Zentren vorbehalten. Die Radiofrequenzablation stellt für gewisse Läsionen wie Zysten und autonome Adenome bei chirurgischer Kontraindikation ein alternatives Ablationsverfahren dar.

Current Practice of Surgery for Benign Goitre-An Analysis of the Prospective DGAV StuDoQ|Thyroid Registry

Background: To evaluate the current indications, resection strategies and short-term outcomes of surgery for benign goitre in a country with endemic goitre. Methods: Data of patients who underwent surgery for benign goitre were retrieved from the prospective StuDoQ/Thyroid registry and retrospectively analysed regarding the patient’s demographics, indications for surgery, surgical procedures, histology, and perioperative outcomes. Results: In a 15-month period, 12,888 patients from 83 departments underwent thyroid resections for benign conditions. Main indications for surgery were exclusion of malignancy (68%), compression symptoms (20.7%) and hyperthyroidism (9.7%). Preoperative fine needle aspiration cytology was performed in only 12.2% of patients with the indication “exclusion of malignancy”. Thyroidectomy (49.8%) or hemithyroidectomy (36.9%) were performed in 86.7% of patients. Minimally invasive or alternative surgical techniques were applied in only 2.2%. Intraoperative neuromonitoring was used in 98.4% of procedures, in 97.5% of patients at least one parathyroid gland was visualized, and in 15.3% of patients parathyroid tissue was autografted, respectively. The rates of unilateral and bilateral transient recurrent nerve palsy were 3.6% and 0.07% of nerves at risk, the rate of transitory hypoparathyroidism was 15.3%. The rates of postoperative bleeding and wound infections requiring reoperation were 1.4% and 0.07%, respectively. Conclusions: The indication “exclusion of malignancy” is made too liberally, and there is a strong attitude to perform complete thyroid resections. Postoperative hypoparathyroidism is the major complication after surgery for benign thyroid disease, thus requiring more awareness.

Medullary Thyroid Carcinoma: Why Is Specialization Mandatory?

Medullary thyroid carcinoma (MTC) represents a distinct form of thyroid cancer with a potentially aggressive behavior, early lymph node metastases, and sporadic as well as hereditary forms. Only surgery with total thyroidectomy and lymph node dissection is able to achieve biochemical cure. Due to the uncommon nature of MTC, a specialization in endocrine surgery for diagnosis as well as therapy of MTC seem to be mandatory for a successful treatment. Knowledge of genotype-phenotype correlations for hereditary forms or routine calcitonin screening for sporadic forms is important to analyze preoperative findings and plan surgical procedures. Postoperative follow-up depends on biochemical cure or monitoring for patients with elevated calcitonin levels.

[Symptomatic hypocalcemia after thyroidectomy : Prevention by a combination of prophylaxis and risk-adapted substitution]

BACKGROUND

Treatment of hypocalcemia after thyroidectomy consists of an individual substitution, prophylaxis or a daily administration of calcium/vitamin D3.

OBJECTIVE

Does prophylactic therapy combined with a risk-adapted substitution of calcium and vitamin D3 reduce symptomatic hypocalcemia compared to individual substitution?

MATERIAL AND METHODS

After implementation of a new algorithm, patient data were prospectively documented and analyzed compared to a historical patient population. The algorithm consisted of a single prophylactic i. v. administration of calcium (1 g calcium gluconate 10% in 250 ml saline) and a risk-adapted oral administration of calcium and vitamin D3 after surgery. Patients without risk (parathyroid hormone, PTH > 15 pg/ml) were not treated. Patients with a low risk (PTH ≥ 6 ≤ 15 pg/ml and Ca > 2.0 mmol/l) received 3 g calcium, patients with a high risk (PTH ≥ 6 ≤ 15 pg/ml and Ca < 2.0 mmol/l) received 3 g calcium and 2 × 0.5 µg vitamin D3 and patients with a very high risk (PTH < 6 pg/ml) got 4 g calcium and 2 × 0.5 µg vitamin D3.

RESULTS

In this study 415 patients were included (230 prospectively and 185 retrospectively). Serum calcium of patients with individual substitution increased significantly at day 1 (p = 0.0001) and the number of patients with critical hypocalcemia (Ca < 2.0 mmol/l) decreased by half (27% vs. 12.2%; p = 0.0001). There was a significantly lower rate of symptomatic patients (24.9% vs 13.0%; p = 0.002) and a clear reduction of patients with a prolonged hospitalization (10.8% vs. 6.5%; p = 0.08). The rate of permanent hypocalcemia was comparable (2.2% vs. 2.1%). In the risk groups there was a significantly different rate of hypocalcemia: patients without risk (n = 170) in 2.2%, patients with low risk (n = 36) in 25%, patients with high risk (n = 13) in 69.2% and patients with very high risk (n = 11) in 71%.

CONCLUSION

This new treatment regimen is practicable, significantly lowers the symptoms, also in comparison to the literature and shows a clear differentiation between the risk groups.