Surgical management of the patient with papillary cancer

The evaluation of the causes of subjective voice disturbances after thyroid surgery

BACKGROUND

Voice changes following thyroidectomy is a rare form of morbidity not infrequently encountered. Injury to the recurrent laryngeal nerve or external branch of the superior laryngeal nerve is the most well-known cause of post-thyroidectomy voice disturbances. However, voice dysfunction is a more complex entity. The aim of the current study was to assess the possible factors that influence voice changes after thyroidectomy.

METHODS

Forty-eight consecutive patients who had undergone thyroidectomy were studied. The acoustic voice analysis (mean vocal fundamental frequency [Fo], mean percentage vocal jitter and shimmer, and noise-to-harmonic ratio) and videolaryngostroboscopic examination of these patients were performed preoperatively, on the second postoperative day, and 3 months after the operation. The presence of subjective voice changes was recorded prospectively based on a symptom scale.

RESULTS

No major complications occurred perioperatively or in the postoperative period. Videolaryngostroboscopic examinations were normal in all patients before and after thyroidectomy. Eighteen (37.5%) patients complained of subjective voice changes in the early postoperative period and 7 (14.6%) of these were still uncomfortable after 3 months. Although the difference was significant by means of all acoustic voice parameters measured in the early postoperative period, Fo is the only parameter that continues to be significant after 3 months.

CONCLUSIONS

Irrespective from recurrent laryngeal nerve and/or injuries to the external branch of the superior laryngeal nerve, voice may temporarily be affected by thyroidectomy. Most of the subjective complaints and acoustic voice parameters return to normal in a few months after surgery.

Radioiodine or surgery for toxic thyroid adenoma: dissecting an important decision. A cost-effectiveness analysis

OBJECTIVE

To examine the cost effectiveness of therapeutic strategies for toxic thyroid adenoma.

DESIGN

Markov state transition decision analytic model.

SETTING

Ambulatory and inpatient.

PATIENTS

Hypothetical cohort of 40- year-old women with toxic thyroid adenomas. Patient age was varied in sensitivity analyses. Data on the prevalence of coincident thyroid cancer, complications, and treatment efficacies were derived from a systematic review of the literature.

INTERVENTIONS

Thyroid lobectomy after a 3 month-course of antithyroid drugs (ATDs), high-dose (<555 MBq) radioactive iodine (RAI), low-dose (>555 MBq) RAI, and lifelong ATDs.

MEASUREMENTS AND MAIN RESULTS

Outcomes were measured in quality-adjusted life years (QALYs). Costs were estimated from the health care system perspective. Future costs and effectiveness were discounted at 3% per year. For a 40- year-old woman, surgery was the most effective, while low-dose RAI was the least costly. The marginal cost-effectiveness of surgery versus low-dose RAI was $13,183 per QALY. Surgery was less costly and more effective than lifelong ATDs. RAI was more effective than surgery if surgical mortality exceeded 0.90% (base-case 0.001%). Surgery provided relatively inexpensive gains (<$50,000 per QALY) in quality-adjusted life expectancy in patients less than 74 years of age.

CONCLUSIONS

For most patients less than 60 years of age, surgery is an effective strategy with a reasonable cost. However, for any given patient, surgical mortality, therapeutic costs and preference must be considered in choosing an appropriate therapy.

Dark and pale cerebriform nuclei in FNA smears of usual papillary thyroid carcinoma and its variants

The dark (hyperchromatic) cerebriform nucleus was recently described as a frequent finding in histopathology sections of papillary carcinoma of the thyroid. In the present study, we tried to determine the frequency of dark cerebriform nuclei in the fine-needle aspiration (FNA) smears of papillary thyroid carcinomas and compared it with those of other thyroid lesions, such as follicular neoplasms and benign hyperplastic lesions. In addition to the above-mentioned nuclear feature, pale (hypochromatic) cerebriform nucleus and other well-established cytomorphological criteria used in the diagnosis of papillary thyroid carcinomas were analyzed. FNA smears of a total of 102 cases comprising of 61 papillary carcinomas, 10 cases of suspicious papillary carcinomas, 12 follicular neoplasms, and 19 benign hyperplastic lesions were studied. Both the dark and pale cerebriform nuclei were found in a significantly higher number of cases of papillary thyroid carcinomas compared with follicular neoplasms (P = 0.0003 and P < 0.0001, respectively) or benign hyperplastic lesions (P = 0.0004 and P < 0.0001, respectively). Review sections available in 24 cases showed agreement between the cytopathological and the histopathological diagnoses in 18 (94.7%) of 19 papillary carcinomas. Thus, the dark and pale cerebriform nuclei can be regarded as useful cytomorphological parameters in the diagnosis of papillary thyroid carcinoma.

New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid

OBJECTIVE

The purpose of our study was to provide new sonographic criteria for fine-needle aspiration biopsy of nonpalpable solid thyroid nodules.

MATERIALS AND METHODS

Sonographic scans of 155 nonpalpable thyroid nodules in 132 patients were prospectively classified as having positive or negative findings. Sonographic findings that suggested malignancy included microcalcifications, an irregular or microlobulated margin, marked hypoechogenicity, and a shape that was more tall than it was wide. If even one of these sonographic features was present, the nodule was classified as positive (malignant). If a nodule had none of the features described, it was classified as negative (benign). The final diagnosis of a lesion as benign (n = 106) or malignant (n = 49) was confirmed by fine-needle aspiration biopsy and follow-up (>6 months) in 83 benign nodules, by fine-needle aspiration biopsy and surgery in 44 malignant and 15 benign lesions, and by surgery alone in five malignant and eight benign lesions. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated on the basis of our proposed classification method.

RESULTS

Of 82 lesions classified as positive, 46 were malignant. Of 73 lesions classified as negative, three were malignant. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy based on our sonographic classification method were 93.8%, 66%, 56.1%, 95.9%, and 74.8%, respectively.

CONCLUSION

Considering the high level of sensitivity of our proposed sonographic classification, fine-needle aspiration biopsy should be performed on thyroid nodules classified as positive, regardless of palpability.

Morphologic predictors of papillary carcinoma on fine-needle aspiration of thyroid with ThinPrep preparations

Although the cytologic features of papillary carcinoma of the thyroid are well-known, none is entirely specific. We conducted this study to determine the minimal criteria necessary to achieve 100% specificity for the diagnosis of papillary carcinoma on fine-needle aspiration (FNA). Forty patients with histologically confirmed papillary carcinoma and 17 patients with other thyroid lesions who underwent preoperative FNA at Beth Israel Deaconess Medical Center during a 4-yr period were included in the study. All cytology slides were prepared with the ThinPrep processing technique. Various architectural and nuclear features were evaluated, with a score assigned to each feature, and correlated with the histologic diagnosis of papillary carcinoma. Intranuclear inclusions, papillary and/or sheet arrangements, nuclear grooves, powdery chromatin, nuclear molding, high cellularity, and small nucleoli were significantly associated with papillary carcinoma (P < 0.05). The requirement of any intranuclear inclusions and many nuclear grooves, or a minimum of sum of scores (of the above eight features) of 10, yields 100% specificity and approximately 70% sensitivity. Cases with fewer features can be reported as suspicious or indeterminate for papillary carcinoma. A quantitative/probabilistic approach in the reporting of thyroid FNA provides a practical guide for management of patients with thyroid nodules.

Initial results from a prospective cohort study of 5583 cases of thyroid carcinoma treated in the united states during 1996. U.S. and German Thyroid Cancer Study Group. An American College of Surgeons Commission on Cancer Patient Care Evaluation study

BACKGROUND

The American College of Surgeons Commission on Cancer (CoC) has conducted national Patient Care Evaluation (PCE) studies since 1976.

METHODS

Over 1500 hospitals with CoC-approved cancer programs were invited to participate in this prospective cohort study of U.S. thyroid carcinoma cases treated in 1996. Follow-up will be conducted through the National Cancer Data Base.

RESULTS

Of the 5584 cases of thyroid carcinoma, 81% were papillary, 10% follicular, 3.6% Hürthle cell, 0.5% familial medullary, 2.7% sporadic medullary, and 1.7% undifferentiated/anaplastic. Demographics and suspected risk factors were analyzed. Fine-needle aspiration of the thyroid gland (53%) or a neck lymph node (7%), thyroid nuclear scan (39%), and ultrasound (38%) constituted the most frequently utilized diagnostic modalities. The vast majority of patients with differentiated thyroid carcinoma presented with American Joint Committee on Cancer Stage I and II disease and relatively small tumors. For all histologies, near-total or total thyroidectomy constituted the dominant surgical treatment. No lymph nodes were examined in a substantial proportion of cases. Residual tumor after the surgical event could be documented in 11% of cases, hypocalcemia in 10% of cases, and recurrent laryngeal nerve injury in 1.3% of cases. Complications were most frequently associated with total thyroidectomy combined with lymph node dissection. Thirty-day mortality was 0.3%; when undifferentiated/anaplastic cancer cases were eliminated, it decreased to 0.2%. Adjuvant treatment, probably underreported in this study, consisted of hormonal suppression (50% overall) and radioiodine (50% overall).

CONCLUSIONS

In addition to offering information concerning risk factors and symptoms, the current PCE study compliments the survival information from previous NCDB reports and offers a surveillance snapshot of current management of thyroid carcinoma in the U.S. Identified opportunities for improvement of care include 1) more frequent use of fine-needle aspiration cytology in making a diagnosis; 2) more frequent use of laryngoscopy in evaluating patients preoperatively, especially those with voice change; and 3) improved lymph node resection and analysis to improve staging and, in some situations, outcomes.

Characteristics and prognostic factors in patients with differentiated thyroid cancer who underwent a total or subtotal thyroidectomy: surgical approach for high-risk patients

Differentiated thyroid cancer grows slowly in general. But some patients repeat recurrence and progress finally to death. To clarify the difference of their prognosis and establish the appropriate thyroid surgery, we studied 105 patients with differentiated thyroid cancer who were treated with total or subtotal thyroidectomy, excluding those with small tumors, under uniform conditions regarding thyroidectomy. There were 77 women and 28 men aged 19 to 76 years (mean 54.7 years). More than 60% (alive) were followed up for longer than 10 years. Thirty-eight (36%) patients had recurrences. There were 19 deaths. Twelve of 31 patients with locoregional recurrence died and 7 of these 12 died of locoregional control failure (neck and mediastinum). Age at first operation, tumor size, and local tumor extension increased the rate of recurrence significantly. Multivariate analysis confirmed that age, locoregional recurrence, and distant metastasis significantly affected survival. Although lymph node metastases were not a prognostic factor, for patients at high risk for recurrence who are older, and have large tumors with invasion, complete resection of cervical lymph nodes is advised to prevent local recurrence and prolong the disease-free interval. Prolongation of the disease-free interval may lead to prolonged survival time.