Evaluation of the clinical value of carbon nanoparticles as lymph node tracer in differentiated thyroid carcinoma requiring reoperation

The advantages of carbon nanoparticles in level VII lymph node dissection in patients with papillary thyroid cancer

Background

The characteristics of level VII lymph nodes were explored and the advantages of using carbon nanoparticles (CNs) in papillary thyroid cancer (PTC) surgeries were examined. This was a retrospective study investigating the clinical data of patients with PTC who underwent surgical treatment.

Methods

From September 2019 to December 2020, a total of 191 consecutive patients with PTC were retrospectively analyzed. The patients were randomly divided into the CNs group and the control group. CNs were used in the CNs group during the operation. There were 103 cases in the CNs group, including 25 males and 78 females, and 88 cases in the control group, including 21 males and 67 females. Parameters, including the characteristics of dissected lymph nodes in level VII, metastatic rate, postoperative complications, and other inpatient-related indicators, were compared between the two groups.

Results

The number of lymph nodes dissected in level VII in the CNs group was significantly greater than that in the control group, and the metastatic rate of black-stained lymph nodes was significantly higher than that of non-black-stained lymph nodes (P<0.05). The postoperative hypoparathyroidism rate in the CNs group was significantly lower than that in the control group (P<0.05). There were no differences in the operation duration, intraoperative blood loss, postoperative drainage duration, or hospitalization days between the two groups (P>0.05).

Conclusions

The application of CNs for patients with PTC significantly increased the number of lymph nodes dissected in level VII and helped to protect the parathyroid glands (PGs). Moreover, the use of CNs did not increase the rate of postoperative complications. Thus, CNs may be a simple and safe approach when performing surgery in PTC patients.

Application of Carbon Nanoparticles in Neck Dissection of Clinically Node-Negative Papillary Thyroid Carcinoma

Purpose

The purpose of this retrospective study was to evaluate the advantages of carbon nanoparticles in neck dissection and to conclude its application in the treatment of clinically node-negative papillary thyroid carcinoma (CN0PTC).

Methods

As a retrospective cohort study, we divided the enrolled patients into two groups, the carbon nanoparticle (CN) group and the control group according to the usage of CN. In the CN group, CN was applied to reveal drainage lymph nodes and the picked LNs were sent for fast frozen testing. If metastasis exits, modified radical lateral lymph node dissection (LLND) was performed. For both groups, prophylactic central lymph node dissection was routinely done. Finally, the demographic information, tumor characteristics, postoperative pathological results, and laboratory data were collected for analysis.

Results

A total of 61 CN0PTC were enrolled in this study, 33 in the CN group and 28 in the control group. The black-stained rate for CN was 29/40 (72.5%) with a positive prediction rate of 34.5%. The mainly black-stained region in the lateral neck was level III and possesses the highest lymph node ratio (17.5%). The metastasis that occurred in level VI was 30% and 11.8% in the CN and control groups, respectively (p = 0.058). During the available follow-up, no one showed recurrence. Statistical analysis showed that the CN suspension can significantly reduce the risk of damage to the parathyroid gland (p = 0.001 for hypocalcemia, <0.05; p = 0.047 for hypoparathyroidism, <0.05).

Conclusion

The lateral neck metastasis in patients with papillary thyroid microcarcinoma in clinical stage cT1aN0 is not rare. CN can help surgeons to distinguish the real person who actually needs LLND. In prophylactic CLND, CN acts as a tracer which makes the parathyroid gland more identifiable and avoids risks of injuries to nerves and glands.

Infiltration of nanocarbon suspension into the tracheal cavity during surgical treatment of papillary thyroid carcinoma: a case report

Cervical lymph node metastasis in patients with differentiated thyroid cancer affects postoperative recurrence and survival. Hypoparathyroidism is caused by parathyroid gland injury during thyroidectomy. Carbon nanoparticles can trace stained lymph nodes, aiding in thorough dissection of lymph nodes in the operation area. To reduce postoperative occurrence of hypoparathyroidism, the parathyroid glands and their functions (identified by negative imaging induced by carbon nanoparticles) are retained in situ. However, the safety and adverse effects of nanocarbon suspension in thyroid surgery have rarely been evaluated. In this report, we describe a patient with thyroid cancer who had carbon secretions in the trachea caused by nanocarbon suspension when tracheal intubation was performed under general anesthesia, and the inflatable balloon surface of the tracheal tube was covered with these secretions. The patient recovered without fever, cough, phlegm production, chest pain, hoarseness, or hypocalcemia-induced convulsions. No consensus has yet been reached on the most appropriate injection site, depth, dose, or waiting time for nanocarbons in thyroid cancer surgery. We believe that nanocarbon suspension is safe for use in thyroid cancer surgery, but the most appropriate injection depth should be based on the thickness of the thyroid gland tissue to avoid deep injection into the trachea.

Preoperative and Intraoperative Methods of Parathyroid Gland Localization and the Diagnosis of Parathyroid Adenomas

Accurate pre-operative determination of parathyroid glands localization is critical in the selection of minimally invasive parathyroidectomy as a surgical treatment approach in patients with primary hyperparathyroidism (PHPT). Its importance cannot be overemphasized as it helps to minimize the harmful side effects associated with damage to the parathyroid glands such as in hypocalcemia, severe hemorrhage or recurrent laryngeal nerve dysfunction. Preoperative and intraoperative methods decrease the incidence of mistakenly injuring the parathyroid glands and allow for the timely diagnosis of various abnormalities, including parathyroid adenomas. This article reviews 139 studies conducted between 1970 and 2020 (49 years). Studies that were reviewed focused on several techniques including application of carbon nanoparticles, carbon nanoparticles with technetium sestamibi (99m Tc-MIBI), Raman spectroscopy, near-infrared autofluorescence, dynamic optical contrast imaging, laser speckle contrast imaging, shear wave elastography, and indocyanine green to test their potential in providing proper parathyroid glands' localization. Apart from reviewing the aforementioned techniques, this study focused on the applications that helped in the detection of parathyroid adenomas. Results suggest that applying all the reviewed techniques significantly improves the possibility of providing proper localization of parathyroid glands, and the application of indocyanine green has proven to be the 'ideal' approach for the diagnosis of parathyroid adenomas.

The role of carbon nanoparticle in lymph node detection and parathyroid gland protection during thyroidectomy for non-anaplastic thyroid carcinoma- a meta-analysis

OBJECTIVE

To assess the efficiency of the carbon nanoparticles (CNs) in lymph node identification and parathyroid gland (PG) protection during thyroidectomy for non-anaplastic thyroid carcinoma (N-ATC).

METHODS

A systematic literature search for relevant literatures published up to December 2018 in PubMed, EMBASE, Web of Science and Cochrane Library was performed. Both English and Chinese literatures were retrieved and analyzed. Randomized controlled trials or nonrandomized controlled trials comparing the use of CNs with the use of methylene blue or a blank control in patients undergoing thyroidectomy for N-ATC were enrolled in this study. The primary outcomes included the number of lymph nodes harvested, the rate of lymph nodes involved, and the rates of accidental parathyroidectomy, hypoparathyroidism, and hypocalcemia. Weighted mean differences (WMDs), odds ratios (ORs) and risk differences (RDs) were calculated for the dichotomous outcome variables. Between study heterogeneity was tested using the Q tests and the I2 statistics. All analyses were performed using Review Manager (version 5.3.5).

RESULTS

25 studies comprising 3266 patients were included in this analysis. The total number of lymph nodes harvested in the CNs groups was significantly higher than that in the control groups (WMD, 2.36; 95% CI, 1.40 to 3.32; P <0.01). Administrating CNs was associated with a lower incidence of accidental PG removal (OR = 0.28, 95% CI = 0.21 to 0.37, P<0.01) and lower rates of both postoperative transient hypoparathyroidism (OR = 0.46, 95% CI = 0.33 to 0.64, P <0.01) and transient hypocalcemia (OR = 0.46, 95% CI = 0.33 to 0.65, P <0.01). No significant difference was found concerning lymph node metastatic rates between CNs group and control group. Subgroup analysis indicated that the application of CNs in reoperation thyroidectomy reduced both the rate of transient hypoparathyroidism (OR = 0.21, 95% CI = 0.06 to 0.75, P = 0.02) and the possibility of accidental PGs removal (OR = 0.21, 95% CI = 0.07 to 0.62, P = 0.004, P<0.05).

CONCLUSIONS

The application of CNs in thyroidectomy for N-ATC results in higher number of lymph node harvested and better PG protection during both initial and reoperation thyroidectomy.

The potential role of carbon nanoparticles-assisted biopsy for sentinel lymph nodes of incidental thyroid carcinoma

Background

Some thyroid cancers are found after thyroidectomy for benign lesions, implying additional surgery and treatments. This work aimed to investigate the role of intraoperative sentinel lymph node biopsy (SLNB) for diagnosis of incidental thyroid carcinoma.

Methods

This was a retrospective study of 541 consecutive patients who underwent thyroid surgery between 02/2012 and 02/2014 at the Hunan Provincial People's Hospital. All patients were diagnosed with thyroid benign lesions preoperatively and intraoperatively. Among them, 375 underwent successful intraoperative SLNB using carbon nanoparticles (CNs).

Results

The preoperative diagnoses were nodular goiter (n=472), Hashimoto's disease with nodules (n=24), hyperthyroidism with nodules (n=16), and thyroid cysts with obstructive symptoms (n=29). In the SLNB group, SLN metastasis of thyroid microcarcinoma was confirmed in 21/392 cases (5.4%). These 21 patients received radical surgical treatment for thyroid carcinoma during the initial operation. In the no-SLNB group (n=149), seven patients (4.7%) were finally diagnosed with thyroid microcarcinoma. Six patients had to undergo a second surgery.

Conclusions

Intraoperative SLNB could help diagnose differentiated thyroid microcarcinoma that may be missed preoperatively and intraoperatively. This could prevent the need for a second surgery since the intraoperative frozen section examination of the SLNs can reveal metastasis from thyroid cancer.

The function of carbon nanoparticles to improve lymph node dissection and identification of parathyroid glands during thyroid reoperation for carcinoma

To evaluate the function of carbon nanoparticles during the thyroid reoperation for carcinoma, we conducted this study by retrospectively analyzing the data of patients who underwent at least completion thyroidectomy with bilateral central lymph nodes dissection for thyroid carcinoma from January 2009 to June 2016. The clinicopathologic characteristics and surgical details were compared between the patient who accepted intraoperative carbon nanoparticles injection and those who accepted nothing injection during the surgery. The main monitoring indicators were the number of dissected lymph nodes and metastatic lymph nodes in central zone, the number of identified parathyroid glands and autoplastic parathyroid glands and unintentionally resected parathyroid glands. A total of 69 patients were enrolled into the carbon nanoparticles group and 128 patients were enrolled into the control group.The average number of lymph nodes harvested in the central zone was higher in the carbon nanoparticles group than that in the control group (11.2 ± 5.7 vs 7.7 ± 4.0, P < .001), so was the average number of metastatic lymph nodes (4.5 ± 4.5 vs 2.7 ± 2.9, P = .004). The average number of identified parathyroid gland was greater in the carbon nanoparticles group than that in the control group (2.4 ± 1.2 vs 1.6 ± 1.1, P < .001). The average number of autoplastic parathyroid gland was comparable between the 2 groups (0.6 ± 0.6 vs 0.4 ± 0.7, P = .052). But the average number of unintentionally resected parathyroid gland was less in the carbon nanoparticles group than that in the control group (0.1 ± 0.2 vs 0.2 ± 0.4, P = .007). Carbon nanoparticles can improve lymph nodes dissection and identification of parathyroid gland during thyroid reoperation for carcinoma.

Non-Canonical Activation of the Epidermal Growth Factor Receptor by Carbon Nanoparticles

The epidermal growth factor receptor (EGFR) is an abundant membrane protein, which is essential for regulating many cellular processes including cell proliferation. In our earlier studies, we observed an activation of the EGFR and subsequent signaling events after the exposure of epithelial cells to carbon nanoparticles. In the current study, we describe molecular mechanisms that allow for discriminating carbon nanoparticle-specific from ligand-dependent receptor activation. Caveolin-1 is a key player that co-localizes with the EGFR upon receptor activation by carbon nanoparticles. This specific process mediated by nanoparticle-induced reactive oxygen species and the accumulation of ceramides in the plasma membrane is not triggered when cells are exposed to non-nano carbon particles or the physiological ligand EGF. The role of caveolae formation was demonstrated by the induction of higher order structures of caveolin-1 and by the inhibition of caveolae formation. Using an in vivo model with genetically modified mice lacking caveolin-1, it was possible to demonstrate that carbon nanoparticles in vivo trigger EGFR downstream signaling cascades via caveolin-1. The identified molecular mechanisms are, therefore, of toxicological relevance for inhaled nanoparticles. However, nanoparticles that are intentionally applied to humans might cause side effects depending on this phenomenon.

Carbon nanoparticles facilitate lymph nodes dissection and parathyroid glands identification in reoperation of papillary thyroid cancer

The aim of the study was to investigate whether carbon nanoparticles (CNs) can improve the dissection of lymph nodes and protect parathyroid glands (PGs) during reoperation for patients with papillary thyroid carcinoma (PTC).PTC patients who previously underwent thyroidectomy and later received reoperation between January 2009 and January 2016 were retrospectively recruited. We compared the patients who had CN suspension injected into the residual thyroid gland with a control group of patients who did not have the injection. The primary endpoints were the number of lymph nodes dissected, the number of PGs identified and reimplanted, and the rate of postoperative hypoparathyroidism.CN suspension injection was conducted in 55 of 174 patients. The total number of lymph nodes and metastatic lymph nodes dissected between the 2 groups were not different (22.8 ± 13.7 vs 21.0 ± 13.3, P = .481 and 5.5 ± 3.8 vs 4.8 ± 4.0, P = .695). The number of central lymph nodes and metastatic central lymph nodes in the CN group was significantly higher than those dissected in the control group (8.7 ± 6.9 vs 6.2 ± 5.2, P = .037 and 2.7 ± 1.9 vs 2.1 ± 1.6, P = .012). More PGs were identified (2.42 ± 1.15 vs 1.58 ± 1.12, P = .001) and fewer were reimplanted (48 vs 90, P = .040) in the CN group. Patients who had CN suspension injection had a lower rate of transient hypoparathyroidism (14/55 vs 50/119, P = .043) but no significant difference in the rate of permanent hypoparathyroidism (1/55 vs 9/119, P = .173).CN suspension injection improves dissection of central lymph nodes and identification of PG in PTC patients undergoing reoperation and lowers the rate of postoperative transient hypoparathyroidism.

Preoperative ultrasound-guided carbon nanoparticles localization for metastatic lymph nodes in papillary thyroid carcinoma during reoperation: A retrospective cohort study

Due to the damaged anatomical structure and a large amount of fibrous and scar tissues in the surgical field, reoperation of papillary thyroid carcinoma is difficult. This study introduces a new method of locating metastatic lymph nodes during reoperation and evaluates the effectiveness and safety of the preoperative ultrasound-guided carbon nanoparticles (CNs) localization. This retrospective cohort study enrolled 52 patients who were diagnosed with lymph node metastasis by histopathology and underwent reoperation from October 2015 to February 2016. The modified radical neck dissection or selective neck node dissection was performed. A total of 26 patients underwent preoperative ultrasound-guided CNs injection, and other 26 patients did not. Tolerance, the result of injection, the number of resected metastatic lymph nodes, and postoperative complications were recorded and analyzed. In CNs group, 102 suspicious nonpalpable lesions in 26 patients were injected with CNs, and 99 of the 102 lesions were successfully identified by surgeon in the reoperation. The positive rate of resected lymph nodes in total, in the central compartment, and in the lateral compartment were 31.6%, 31.2%, and 32.8%, respectively, which was significantly higher than that in the control group (P < 0.001, P < 0.001, and P = 0.041). In addition, the positive rates of levels III, IV, and V in the CNs group were 35.6%, 21.9%, and 30.5%, respectively, which was significantly higher than that in the control group (P < 0.001, P = 0.005, and P = 0.01). In additional, in the CNs group, the rate of temporary hypoparathyroidism was significantly lower compared with the control group (0% vs 26.9%, P = 0.021). Preoperative ultrasound-guided CNs injection is a safe and effective method for localization of the metastatic lymph nodes during reoperation.

Significance of clearing differentiated thyroid carcinoma lymph node by high-frequency color Doppler ultrasonography

We compared the clinical effects and prognosis of patients receiving lymph node dissection after surgical removal of the thyroid tissues and those not receiving it after the removal. A total of 80 patients diagnosed with differentiated thyroid carcinoma (DTC) by our hospital from March 2012 to March 2014 were successively included in the study. The cases were divided into the control group (n=36 cases) and observation group (n=44 cases), and the two groups underwent total or subtotal resection of the thyroid. In the control group, patients underwent preoperative high-frequency color ultrasonography, and the most suspicious lymph node was removed. In the observation group, patients underwent preoperative high-frequency color ultrasonography, and the surgeons cleared the lymph node of the widest range. Difference in clinical effects and prognosis of the two groups were compared. After nearly a year's follow-up observation, the tumor recurrence rate of the observation group was significantly lower than that of the control group and the survival rate of the observation group was significantly higher than that of the control group (P<0.05). The rate of surgery complications and comparative difference of the two patient groups had no statistical significance (P>0.05). When comparing the data of lymphatic metastasis tested by preoperative high-frequency color ultrasonography with intraoperative diagnosed figures, sensitivity was 97.4%, specificity 33.3%, positive predictive value 90.2% and the negative predictive value 66.7%. In conclusion, removal of the lymph node for DTC patients having undergone thyroid tissue excision with preoperative high-frequency color ultrasonography can be beneficial to improve the effects along with reduction in the recurrence rate.

Potential role of carbon nanoparticles in protection of parathyroid glands in patients with papillary thyroid cancer

As a novel type of lymphatic tracer, carbon nanoparticles (CNs) were reported not to stain parathyroid glands (PGs) into black, so it may have a clinical potential in protection of PGs during thyroidectomy. The purpose of this study was to investigate the clinical application and significance of CN in protection of PGs from surrounding tissues.A total of 82 consecutive patients were enrolled into this study and were divided into CN group and control group. Parathyroid function (hypoparathyroidism and hypocalcemia) was evaluated.The identification rates of PGs (≤2) and PGs (≥3) were 24.4% and 75.6% in the CN group and 46.3% and 53.7% in the control group, respectively. The difference in the identification rates between the 2 groups was statistically significant (P = 0.038). Pathological results revealed 3 accidental PGs resection occurred in the CN group, whereas 9 accidental PGs removal occurred in the control group. The difference was statistically significant (P = 0.046). Moreover, the incidence of the patients with hypoparathyroidism was statistically significant between the 2 groups (36.6% in CN group vs 53.7% in control group, P = 0.043) at day 1, but not at day 7 (P = 0.424).CN may have a potential in protecting PGs clinically.