Management of the Neck in Well-Differentiated Thyroid Cancer

Perceived barriers and factors influencing uptake of breast cancer screening among women: a population-based cross-sectional study

Breast cancer (BC) screening plays a major role in the prevention of BC through early detection and timely treatment. This study aims to determine the level of uptake of BC screening and associated factors. A community-based analytical cross-sectional study was conducted in Dodoma City, Tanzania from July to December 2020. The study included women aged 8 years and above without a known history of breast cancer. Multivariable logistic regression was used to determine the socio-demographic factors associated with BC screening. P value < 0.05 was considered significant. A total of 354 study participants were included in the present study. The mean age of participants was 31.0 ± 11.8 years. The majority of study participants (67.5%, n = 239) were aware of BC screening. However, only (35.3%, n = 125) reported to have ever practised BC screening. Breast self-examination was the most (16.4%, n = 58) frequently used method for BC screening among study participants. Lack of knowledge of all methods of BC screening was the barrier that was perceived by the vast majority (60.2%, n = 213) of the study participants. Having low family income was the only predictor of failure to practice BC screening. In this study, most of the women were aware of BC, however, few of them had undergone breast cancer (BC) screening at the time of the interview. The study also found that the main barrier to BC screening was the lack of knowledge about BC among the study participants. Immediate measures are necessary to increase women's awareness of BC. Such as community sensitization on the importance of screening, can help improve the uptake of BC screening and the early detection of BC.

Drawing as a Way of Knowing: How a Mapping Model Assists Preoperative Evaluation of Patients with Thyroid Carcinoma

Background: Effective pre-surgical planning is crucial for achieving successful outcomes in endocrine surgery: it is essential to provide patients with a personalized plan to minimize operative and postoperative risks. Methods: Preoperative lymph node (LN) mapping is a structured high-resolution ultrasonography examination performed in the presence of two endocrinologists and the operating surgeon before intervention to produce a reliable "anatomical guide". Our aim was to propose a preoperative complete model that is non-invasive, avoids overdiagnosis of thyroid microcarcinomas, and reduces medical expenses. Results: The use of 'preoperative echography mapping' has been shown to be successful, particularly in patients with suspected or confirmed neoplastic malignancy. Regarding prognosis, positive outcomes have been observed both post-surgery and in terms of recurrence rates. We collected data on parameters such as biological sex, age, BMI, and results from cytologic tests performed with needle aspiration, and examined whether these parameters predict tumor malignancy or aggressiveness, calculated using a multivariate analysis (MVA). Conclusions: A standard multidisciplinary approach for evaluating neck lymph nodes pre-operation has proven to be an improved diagnostic and preoperative tool.

Disease-free survival and response to therapy of clinically node- negative Papillary Thyroid Cancer treated without central neck dissection: Retrospective study of 321 patients

BACKGROUND AND OBJECTIVE

Nodal metastases in the central compartment are frequent in papillary thyroid cancer (PTC). However, they are mostly micrometastases with no impact on survival and their relevance on the risk of locoregional relapse is controversial. There is no consensus regarding optimal management of the central neck in patients with PTC cN0. In our center, we do not perform prophylactic central neck dissection (pCND). The objective of this study is to review our long-term results and compare them with the most recent literature.

PATIENTS AND METHODS

Retrospective review of patients with PTC who underwent total thyroidectomy (TT) without CND between 2005 and 2017. Primary result was disease-free survival in the neck (DFS).

RESULTS

321 patients were identified, mostly T1-T2 tumors (94.1%). Median follow-up was 90 months. DFS in the central compartment was excellent (96.1% at 10 year's follow-up). 19 patients had cervical recurrence, of which 15 underwent salvage surgery. On their last visit, including salvage surgery when appropriate, 77% of patients had excellent response, 18.7% had indeterminate response, 3.1% had biochemically incomplete response and 1.2% had morphologically incomplete response. Recurrent laryngeal nerve (RLN) paralysis after TT was transient in 4.7% of patients and permanent in 0.9% of patients. There were no RLN paralysis after salvage surgery. Permanent hypoparathyroidism occurred in 3.4% of patients. Only one patient had hypoparathyroidism after salvage surgery and it was permanent.

CONCLUSIONS

Based on long-term results and low rate of complications associated with salvage surgery in our experience, we consider routine pCND is not justified.

Recurrent Differentiated Thyroid Cancer: The Current Treatment Options

Differentiated thyroid carcinomas (DTC) have an excellent prognosis, but this is sometimes overshadowed by tumor recurrences following initial treatment (approximately 15% of cases during follow-up), due to unrecognized disease extent at initial diagnosis or a more aggressive tumor biology, which are the usual risk factors. The possible sites of recurrence are local, regional, or distant. Local and regional recurrences can usually be successfully managed with surgery and radioiodine therapy, as are some isolated distant recurrences, such as bone metastases. If these treatments are not possible, other therapeutic options such as external beam radiation therapy or systemic treatments should be considered. Major advances in systemic treatments have led to improved progression-free survival in patients previously considered for palliative treatments; among these treatments, the most promising results have been achieved with tyrosine kinase inhibitors (TKI). This review attempts to give a comprehensive overview of the current treatment options suited for recurrences and the new treatments that are available in cases where salvage surgery is not possible or in cases resistant to radioiodine.

The lymph node yield in the initial lateral neck dissection predicts recurrence in the lateral neck of papillary thyroid carcinoma: a revision surgery cohort study

BACKGROUND

This study aimed to evaluate the relationship between lateral lymph node yield (LLNY) and the ratio of lateral positive lymph nodes to lymph node yield (LPLR) from initial lateral neck dissection (LND) in patients with papillary thyroid carcinoma (PTC), as well as the risk of recurrence in patients undergoing LND reoperations.

METHODS

This retrospective cohort study enrolled patients with PTC who underwent revision LND between 1 January 2012, and 31 December 2021. The initial and revised clinical data were retrieved. Patient demographics, clinicopathological features, clinical records, and follow-up information were also reviewed. LLNY and LPLR were determined during the initial LND.

RESULTS

In total, 156 patients with PTC were included in this study, with a median follow-up of 36.5 months; 107 had recurrent lateral neck disease. The optimal LLNY and LPLR cutoff values for recurrent/persistent disease were 24.5 and 32.74%, respectively. The high-risk group (LLNY<25) had the lowest recurrence-free survival rate compared with to moderate-risk group (LLNY≥25, LPLR≥32.74%) and low-risk group (LLNY≥25, LPLR<32.74%) ( P <0.001). The moderate-risk group had lower recurrence-free survival than the low-risk group. Multivariate analysis revealed that an LLNY less than 25 in the initial LND was an independent risk factor for recurrence/persistence of lateral neck ( P <0.001).

CONCLUSIONS

This study identified that LLNY and LPLR were associated with recurrence/persistence in PTC patients at the time of revision surgery was performed.

Neck Surgery for Non-Well Differentiated Thyroid Malignancies: Variations in Strategy According to Histopathology

Lymph node metastases in non-well differentiated thyroid cancer (non-WDTC) are common, both in the central compartment (levels VI and VII) and in the lateral neck (Levels II to V). Nodal metastases negatively affect prognosis and should be treated to maximize locoregional control while minimizing morbidity. In non-WDTC, the rate of nodal involvement is variable and depends on the histology of the tumor. For medullary thyroid carcinomas, poorly differentiated thyroid carcinomas, and anaplastic thyroid carcinomas, the high frequency of lymph node metastases makes central compartment dissection generally necessary. In mucoepidermoid carcinomas, malignant peripheral nerve sheath tumors, sarcomas, and malignant thyroid teratomas or thyroblastomas, central compartment dissection is less often necessary, as clinical lymphnode involvement is less common. We aim to summarize the medical literature and the opinions of several experts from different parts of the world on the current philosophy for managing the neck in less common types of thyroid cancer.

Management of Recurrent Well-Differentiated Thyroid Carcinoma in the Neck: A Comprehensive Review

Surgery has been historically the preferred primary treatment for patients with well-differentiated thyroid carcinoma and for selected locoregional recurrences. Adjuvant therapy with radioactive iodine is typically recommended for patients with an intermediate to high risk of recurrence. Despite these treatments, locally advanced disease and locoregional relapses are not infrequent. These patients have a prolonged overall survival that may result in long periods of active disease and the possibility of requiring subsequent treatments. Recently, many new options have emerged as salvage therapies. This review offers a comprehensive discussion and considerations regarding surgery, active surveillance, radioactive iodine therapy, ultrasonography-guided percutaneous ablation, external beam radiotherapy, and systemic therapy for well-differentiated thyroid cancer based on relevant publications and current reference guidelines. We feel that the surgical member of the thyroid cancer management team is empowered by being aware and facile with all management options.

The effect of thymectomy during central neck dissection in papillary thyroid carcinoma: a case-controlled study

Central lymph-node dissection (CND) as part of total thyroidectomy is recommended in the treatment of papillary thyroid cancer. CND with thymus resection for achieving more oncological clearance is suggested in guidelines, but the benefits of this technique are still unclear due to the risk of parathyroid glands injury and postoperative hypocalcemia. The aim of this study is to evaluate the risk and benefits of thymectomy in CND with total thyroidectomy. We retrospectively reviewed the records of 188 patients with total thyroidectomy and CND. Participants were divided into 110 patients with CND and thymus resection and 78 patients with thymus preservation. Oncological completeness was evaluated by measuring the postoperative thyroglobulin and hypocalcemia as a postoperative complication was measured by blood calcium level. Based on our findings, patients who underwent thymus resection had a higher incidence of hypocalcemia compared to patients with thymus preservation (56.4% vs. 39.2%; P = 0.027), but there was no significant difference in thyroglobulin levels between these two groups. (P = 0.115 and 0.185, respectively) The proportion of involved to total resected lymph nodes in our study was 28%, which did not statistically differ among the thymus groups. Routine thymus resection during the CND and total thyroidectomy is not recommended because of more postoperative hypocalcemia occurrence and minimal oncological benefit in PTC treatment.

The Necessity of Lymph Node Dissection Between Sternocleidomastoid and Sternohyoid Muscles in pN1b Papillary Thyroid Carcinoma

BACKGROUND

This study aimed to evaluate the association between clinicopathologic variables and metastasis of the lymph node (LN) between the sternocleidomastoid and sternohyoid muscles (LNSS) to clarify the necessity of LNSS dissection in papillary thyroid carcinomas (PTCs).

METHODS

A total of 219 patients undergoing unilateral or bilateral neck dissection for PTCs were prospectively enrolled. The associations between clinicopathologic variables and LNSS metastasis were evaluated by univariate and multivariate analyses.

RESULTS

LNSS was present in 108 (40.1%) neck dissection samples and in 76 (34.7%) patients. Positive LNSS occurred in 40/269 (14.9%) neck dissection samples and in 20/219 (9.1%) patients. Univariate analysis showed that tumor stage, number of positive nodes in level III, and number of positive nodes in level IV were related to LNSS metastasis. Multivariate analysis confirmed that T3/4 stage tumors and >2 positive LNs in level IV independently increased the risk of LNSS metastasis.

CONCLUSIONS

The low rate of LNSS metastasis would deem routine dissection unnecessary; however, LNSS would require excision if advanced stage tumors or level IV LN metastasis were present.

Effects of Central Neck Dissection on Complications in Differentiated Thyroid Cancer

Objective

It is still controversial whether performing central neck dissection (CND) in addition to total thyroidectomy (TT) increases the risk of complications. In the present study, we aimed to evaluate the effect of CND on the development of complications in differentiated thyroid cancer (DTC) compared to TT.

Material and Methods

The data of 186 patients (136 females and 50 males) with a mean age of 48.73±14.78 (range, 17-82) whom were operated for DTC were evaluated retrospectively. The patients were divided into two groups; TT (Group 1) and CND±TT/Completion thyroidectomy±lateral neck dissection (Group 2).

Results

There were 117 (91 F, 26 M) patients in Group 1 and 69 (45 F, 24 M) patients in Group 2. Parathyroid auto transplantation (PA) was significantly higher in Group 2 compared to Group 1 (42% vs. 6%) (p=0.000). Total (58% vs. 21.4%, respectively; p=0.000) and transient hypoparathyroidism (52.2% vs. 20.5%, respectively; p=0.000) were significantly higher in Group 2 than in Group 1, but permanent hypoparathyroidism rates were statistically not significant (5.8% vs. 0.9%, respectively; p=0.064). In the multinomial logistic regression analysis, CND alone was determined as an independent risk factor for increased both total and transient hypoparathyroidism. The relative risk (RR) of CND for total hypoparathyroidism was 5.2 times increased (odds ratio [OR]: 0.192) (p=0.007), while the RR for transient hypoparathyroidism was 3.5 times increased (OR: 0.285) (p=0.036). According to the number of nerves at risk, CND was performed in 119 neck side and only thyroidectomy was performed in 253 neck side. Total vocal cord paralysis (VCP) rate (9 [7.6%] vs. 6 [2.4%], respectively) (p=0.017) and transient VCP rate (7 [6%] vs. 4 [1.6%], respectively) (p=0.021) in patients who underwent CND were significantly higher compared to those who underwent only thyroidectomy. In multinomial logistic regression analysis performing only CND was an independent risk factor for total VCP, and increased the total VCP RR approximately 5.34 times (OR:0.184; p=0.007).

Conclusion

Although CND can be applied without increasing the rates of permanent hypoparathyroidism and VCP compared to TT, it increases the risk of total and transient hypoparathyroidism, total, and transient VCP. Patients undergoing CND should be followed carefully in terms of transient hypoparathyroidism.

Ultrasound and Contrast-Enhanced Ultrasound Characteristics Associated With cN1 and Microscopic pN1 in Papillary Thyroid Carcinoma

OBJECTIVES

Lymph node metastases (LNMs) could be stratified into clinical N1 (cN1) and microscopic pN1 (pathological N1), which bear different biological behavior and prognosis. Our study aimed to investigate the associations between LNMs and primary tumor's US (ultrasound) and CEUS (contrast-enhanced ultrasound) characteristics based on the stratification of LNMs into cN1 and microscopic pN1 in papillary thyroid carcinoma (PTC).

METHODS

From August 2019 to May 2020, 444 consecutive PTC patients who underwent preoperative neck US and CEUS evaluation were included. According to regional lymph node status, the patients were classified into cN1 group versus cN0 (clinical N0) group and microscopic pN1 group versus pN0 (pathological N0) group. For multiple PTCs, the largest one was selected for the evaluation of US, CEUS and clinical features. Univariate and multivariate analyses were performed to determine independent predictors of cN1 and microscopic pN1.

RESULTS

85 cN1 versus 359 cN0 patients and 117 microscopic pN1 versus 242 pN0 patients were analyzed. Multivariate logistic regression analysis showed that <55-years-old (OR: 2.56 (1.08-6.04), male [OR: 2.18 (1.22-3.91)], large size [OR: 2.59 (1.71-3.92)], calcification [OR: 3.88 (1.58-9.51)], and hyper-enhancement [OR: 2.78 (1.22-6.30)] were independent risk factors of cN1, while <55-years-old [OR: 1.91 (1.04-3.51)], large size [OR: 1.56 (1.003-2.42)], multifocality [OR: 1.67 (1.04-2.66)] were independent risk factors of microscopic pN1.

CONCLUSIONS

For patients with PTC, young age, male, large size, calcification, and hyper-enhancement were independent predictors of cN1, while young age, large size and multifocality were independent predictors of microscopic pN1.