Soft tissue implantation of thyroid adenomatous hyperplasia after endoscopic thyroid surgery

Track recurrence after remote-access thyroid surgeries: A systematic review

BACKGROUND

Remote-access thyroidectomies have gained popularity, but track recurrence, which is the implantation of thyroid tissue or lesions along the surgical access route, has been reported in case studies. This systematic review aims to review cases of track recurrence following remote-access thyroidectomies.

METHODS

A comprehensive literature search was conducted using PubMed, the Web of Science, the Cochrane Library, and Google Scholar to identify case reports on track recurrence after endoscopic or robotic thyroidectomy up to June 2024. Data included patient demographics, details of the initial surgery and diagnosis, methods and timing of recurrence detection, and management strategies.

RESULTS

The search yielded 1578 articles, of which 17 case reports comprising 18 patients were included. The patients (16 females and two males) had a mean age of 34.6 ± 14.9 years. The mean size of initial tumors was 3.9 ± 1.2 cm, with diagnoses of eight cancers and 10 benign lesions. The initial surgeries included 12 endoscopic and six robotic procedures. Track recurrence was most often detected by palpable nodules followed by routine imaging and elevated serum Tg levels. The interval between initial surgery and recurrence ranged from 3 months to 8 years. Management varied from surgical resection and radioactive iodine therapy to close observation. There were no further recurrences in all but one case postoperatively.

CONCLUSION

Track recurrence after remote-access thyroidectomy is rare but significant. Proper surgical techniques, careful handling of thyroid tissue, and rigorous postoperative monitoring are essential to minimize this risk. Awareness and prompt management of track recurrence may lead to favorable outcomes.

Subcutaneous implantation of nodular goiter after transoral endoscopic thyroidectomy vestibular approach: A case study and review of literature

BACKGROUND

Extrathyroid implantation or dissemination of thyroid tissue secondary to a thyroid procedure is rare. Most of these belonged to thyroid carcinoma with metastatic potential and uncommon for benign pathologies.

METHODS

We report the case of a 31-year-old female who was identified to have multiple subcutaneous implantation of thyroid tissue 5 years after transoral endoscopic thyroidectomy vestibular approach. A comprehensive literature search on implantation of thyroid tissue secondary to thyroid procedures was performed.

RESULTS

Accidental tearing of the capsule during previous surgery may lead to the subcutaneous implantation. Through literature review, a total 29 articles with 47 patients were identified. 33.3% were benign lesions, and implantation was mostly secondary to fine needle aspiration biopsy (46.5%).

CONCLUSIONS

Subcutaneous or port site implantation after endoscopic thyroid surgery may occur in benign thyroid pathologies and therefore, oncologic principles must be strictly followed during surgery regardless of its histopathological nature.

Beware the recurrent 'benign' multinodular goitre

BACKGROUND

The diagnosis of follicular carcinoma is often difficult to make on pathological analysis, as the histological distinction from follicular adenoma rests solely on the presence of capsular or vascular invasion. Even on retrospective review of the histopathology after the disease biology has declared itself as malignant, the pathological diagnosis of malignancy may not be possible to make.

METHODS

We report three cases in which patients were initially diagnosed with benign follicular lesions, but re-presented with locally recurrent disease and a subsequent malignant disease course.

RESULTS

We describe a rare entity of follicular thyroid carcinoma that demonstrates a locally recurrent and eventually metastatic disease phenotype, despite persistently benign pathological findings.

CONCLUSION

We highlight that if local recurrence occurs in discrete anatomical tissue planes, or in the thyroid bed following open total thyroidectomy for 'benign multinodular goitre', the possibility of this rare presentation of follicular thyroid carcinoma should be considered.

En bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in papillary thyroid carcinoma

INTRODUCTION

The current study presents a preliminary exploration of en bloc resection via a gasless transoral approach in papillary thyroid carcinoma.

OBJECTIVE

This study aimed to summarize and explore the efficacy and safety of en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach in patients with papillary thyroid carcinoma.

METHODS

This study was conducted between January 2021 and December 2021. It involved 30 patients with bilateral papillary thyroid carcinoma who had undergone en bloc resection of the total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach using a three-trocar and four-instrument technique at The First Affiliated Hospital of the University of Science and Technology of China. The key steps and difficulties of the operation were summarized, and the clinicopathological characteristics and surgical complications of patients were analyzed.

RESULTS

All operations were successful without conversion to open surgery. The pathological diagnosis was bilateral papillary thyroid carcinoma. The mean maximum tumor diameter was 0.85 ± 0.51 cm (range 0.3-2.5 cm). There was no case of gross capsular invasion. The mean number of harvested central compartment lymph nodes was 11.36 ± 5.36. Central compartment lymph node metastases were found in 16 patients (53.3%) with a mean of 1.53 ± 2.39. On the other hand, lymphocytic thyroiditis was observed in 12 cases (40%), and microscopic capsular invasion was observed in five cases (16.6%). All patients had normal parathyroid hormone levels after the operation. However, one patient developed hoarseness after the operation due to injury of the recurrent laryngeal nerve branch, but there was no numbness of the mandible and lower lip or infection of the oral incision.

CONCLUSION

The study revealed that the three-trocar and four-instrument technique can be used in the en bloc resection of total thyroid and bilateral central compartment lymph nodes via a gasless transoral approach without disconnecting the thyroid isthmus. As a result, the operation is considered effective and safe. Therefore, this technique may be a better surgical method for patients with bilateral thyroid cancer and cosmetic needs.

Case Report: Implantation of Dedifferentiated to Poorly Differentiated Thyroid Carcinoma After Endoscopic Thyroid Surgery

Background

Endoscopic thyroidectomy is widely accepted for its advantages. However, implant metastasis remains a significant complication of endoscopic thyroidectomy.

Methods

This is the first report of breast implantation diagnosed with poorly differentiated thyroid carcinoma following endoscopic thyroidectomy.

Results

We present a case of a 35-year-old woman who was initially diagnosed with a 3.0 cm conventional papillary thyroid carcinoma after endoscopic thyroidectomy via total areola. Two years later, she was reported to have recurring poorly differentiated thyroid carcinoma in the right areola. Implantation after endoscopic thyroidectomy is rare, and even rarer is dedifferentiated papillary thyroid carcinoma around the implant site.

Conclusions

Stringently evaluated endoscopic surgery indications, appropriate preoperative evaluation, meticulous surgical technique, and adequate protective measures can significantly reduce the incidence of local implantation or recurrence.

Postsurgical complications after robot-assisted transaxillary thyroidectomy: critical analysis of a large cohort of European patients

In the last decade, robot-assisted trans-axillary thyroidectomy has spread rapidly and has been proven to be a safe and effective procedure. However, several case series have reported new complications that have led to criticism regarding this approach. This study analyzed the incidence of complications in a large cohort of European patients. We enrolled all patients who underwent robot-assisted trans-axillary thyroidectomy from 2012 to 2020 at the University Hospital of Pisa Department of Endocrine Surgery. We analyzed complications and divided them into 2 groups. Group A included conventional complications, such as transient or permanent recurrent laryngeal nerve palsy, transient or permanent hypocalcemia, hemorrhage, and tracheal injury. Group B included unconventional complications, such as brachial plexus palsy, track seeding, seroma, great vessels injury, and skin flap perforation. There were 31 postsurgical complications (5.7%). Group A included 25 complications (4.6%): transient and permanent recurrent laryngeal nerve palsy occurred in 7 patients (1.3%) and in 1 (0.2%), respectively; transient and permanent hypocalcemia occurred in 9 patients (1.7%) and in 1 (0.2%), respectively. Postoperative bleeding occurred in 6 patients (1.1%) and tracheal injury in 1 (0.2%). Group B included 6 complications (1.1%): 1 patient with brachial plexus injury (0.2%), 1 with track seeding (0.2%), and 4 with seroma (0.7%). Robotic trans-axillary thyroidectomy is a safe approach with a risk of postoperative complications comparable to the conventional technique. Almost all complications after a novel introduction are anecdotal. With an accurate patient selection, high-volume institutions with experienced surgeons can perform this technique safely.

First report of benign track seeding after robot-assisted transaxillary thyroid surgery

BACKGROUND

Robot-assisted transaxillary thyroidectomy is a well-established remote-access thyroid procedure that has been demonstrated to be as safe and effective as its time-honored conventional clamp-and-tie counterpart. However, it has been incriminated for a set of unprecedented complications that surgeons need to be aware of and deal with appropriately.

PATIENT FINDINGS

The patient is a young woman who underwent robot-assisted thyroid lobectomy for a sizeable nodule that was reported as benign after fine-needle aspiration cytology. She presented 3 years later with subcutaneous nodules along the surgical track that were found to represent seeding of benign thyroid tissue. This is the first report of benign thyroid tissue seeding after a gasless transaxillary procedure.

SUMMARY

Seeding along the surgical track is a potential complication of gasless remote-access thyroid surgery, even in case of benign disease, that surgeons need to be acquainted with.

CONCLUSIONS

Surgeons should be aware of the potential for benign seeding after remote-access thyroid procedures. Accordingly, adequate precautions should be taken, patients should be counseled in this regard, and alternative medical strategies to control local seeding of thyroid tissue could be suggested.

Unilateral Axilla-Bilateral Areola Approach for Thyroidectomy by da Vinci Robot: 500 Cases Treated by the Same Surgeon

Objective: To investigate the efficacy and safety of da Vinci robot-assisted thyroidectomy via an unilateral axilla-bilateral areola (UABA) approach. Methods: The clinical data of 500 patients undergoing robotic thyroidectomy via an UABA approach from July 2014 to April 2018 were retrospectively analyzed. All 500 patients were operated on by the same surgeon and divided into two groups by the time sequence. The efficacy and complications were compared between the two groups. Results: Robotic thyroidectomy via an UABA approach was performed successfully in 500 cases, including 196 cases of benign thyroid diseases with a lesion diameter of 3.1 ± 1.3 cm (0.4 - 8.2 cm) and 304 cases of thyroid cancer with a tumor diameter of 1.2 ± 0.7 cm (0.4 - 4.4 cm). Surgical procedures included unilateral lobectomy and total thyroidectomy with or without central lymph node dissection. Among the 500 patients, 9 (1.8%) had transient recurrent laryngeal nerve injury, 1 (0.2%) had permanent unilateral recurrent laryngeal nerve injury, 12 (2.4%) had subcutaneous hemorrhage of the trajectory area, and 6 (1.2%) had subcutaneous infection of the trajectory area after surgery. Among 239 thyroid cancer patients undergoing total thyroidectomy, 45 (18.8%) had transient hypoparathyroidism and 5 (2.1%) had permanent hypoparathyroidism. The incidence of permanent hypoparathyroidism was 1.9% (4/212) among the patients undergoing total thyroidectomy plus unilateral central lymph node dissection, and 3.7% (1/27) among the patients undergoing total thyroidectomy plus bilateral central lymph node dissection. During the follow-up of median 17 months, all patients were satisfied with postoperative appearance of the neck and no structural recurrence or metastases occurred. There was no significant difference in efficacy between the two groups (P > 0.05), while the complication rate in phase 2 was significantly lower than that in phase 1 (P < 0.05) as the surgeon became more proficient in the UABA approach. Conclusion: Robotic thyroidectomy via an UABA approach is simple, safe, and minimally invasive, suitable for radical resection of large benign tumors and early thyroid cancer and central lymph node dissection.

Multifocal recurrence on the transaxillary robotic thyroidectomy incision

INTRODUCTION

Robotic thyroidectomy (RT) has been reported to achieve satisfactory results. However, its long-term oncological results have not been validated. The use of RT to treat thyroid cancer comprises specific risks that are not encountered with open thyroidectomy (OT).

CASE SUMMARY

We report the case of a patient operated by two-stage RT for stage pT3a follicular carcinoma, followed by tumour seeding along the incision despite adjuvant Iodine-131 therapy and external beam radiotherapy.

DISCUSSION

This case illustrates the limitations and insufficient perspective of RT for thyroid cancer, with the recent discovery of a risk of tumour seeding along the incision. Rigorous patient selection should help to avoid this risk of tumour seeding.

Hürthle Cells Adenoma of the Thyroid with Post-surgical Implants in the Neck: Clinical, Morphological, and Molecular Analysis of Three Cases

Thyroid implants in the soft tissue of the neck are very rare findings of traumatic, iatrogenic, or neoplastic origins. We describe the clinico-pathological and molecular analysis of three cases with an initial diagnosis of follicular adenoma, Hürthle cell variant (FA-HCT), which developed cervical thyroid implants at 60, 59, and 36 months after thyroid surgery, followed by further neck recurrences, and, eventually, by distant metastases. A systematic review of all histopathological samples of both the primary lesions and the neck implants was performed. Molecular study included the analysis of pan-RAS and BRAF mutations and RET/PTC1, RET/PTC3, and PAX8/PPARγ rearrangements. The review of the original slides and of additional re-cuts of each block of the thyroid lesions did not show any sign of capsular and/or vascular invasion; thus, the original diagnoses of FA-HCT were confirmed. When sampling adequacy was considered, it turned out that the capsule was completely evaluable in case #3, whereas 85 % was evaluable for case #1 and less than 50 % for case #2. We cannot exclude that cases #1 and #2 were carcinomas that had not been completely sampled. The first occurring neck implants showed neither histological signs of malignancy nor the presence of lymphoid tissue. However, further neck recurrences had different histological aspects, with a clear infiltrative growth. Moreover, a mesenchymal reaction forming a sort of capsule was observed around oncocytic cells along with signs of vascular invasion. Molecular analysis revealed no alterations in the genes and rearrangements studied. Oncocytic thyroid implants in the neck soft tissue should be regarded as metastasis, even in the absence of clear-cut signs of malignancy and in the case of a bona fide diagnosis of Hürthle cells adenoma of the thyroid.

Track Recurrence After Robotic Transaxillary Thyroidectomy: A Case Report Highlighting the Importance of Controlled Surgical Indications and Addressing Unprecedented Complications

BACKGROUND

Robot-assisted transaxillary thyroid surgery (RATS), widely accepted and used in Asian countries, can be an appealing treatment option both for patients with major concerns regarding a cervical scar and for their surgeons. Patients benefit from scarless neck surgery, while their surgeons benefit from improved dexterity and ergonomics compared with remote-access endoscopic thyroid surgery. However, validating any novel surgical procedure for thyroid pathology should be based on evidence regarding its feasibility, radicality, and safety compared to the time-honored, safe and effective, conventional open thyroidectomy. It should also be evaluated for potential risks that are not present with conventional approaches.

PATIENT FINDINGS

This study reports a patient with surgical track and cervical nodal recurrence, and distant metastasis following a two-stage robot-assisted surgery, and radioactive iodine ablation therapy for a papillary thyroid carcinoma that was initially regarded a single indeterminate nodule.

SUMMARY

This case emphasizes the importance of thoroughly evaluating the oncological safety of RATS, and points out the possibility of "malignant seeding along the surgical access" being an untraditional potential complication associated with the procedure.

CONCLUSIONS

While tailoring the surgical strategy to the patients' concerns and desires is important, adhering to fundamental onco-surgical principles is a priority. Furthermore, unconventional complications associated with novel surgical procedures should be properly evaluated and addressed.

Extrathyroidal implantation of thyroid hyperplastic/neoplastic cells after endoscopic thyroid surgery

OBJECTIVE

To report a case of the implantation of thyroid hyperplastic or neoplastic tissue after endoscopic thyroidectomy and discuss this complication in aspects of prevalence, pathogenesis, protection, and therapies.

METHODS

A systematic search of literature from the PubMed database was conducted for identifying eligible studies on implantation of thyroid hyperplastic or neoplastic cells after endoscopic thyroid surgery.

RESULTS

Overall, 5 reported cases on patients suffering from endoscopic thyroid surgery with implantation of thyroid hyperplastic or neoplastic cells were included in the systematic review.

CONCLUSIONS

Unskilled surgeons, rough intraoperative surgical treatment, scarification or rupture of tumor, contamination of instruments, chimney effect, aerosolization of tumor cells may be associated with the implantation after endoscopic thyroidectomy. To minimize the risk of such complication, we should be more meticulous and strict the endoscopic surgery indications.

Multinodular goitre arising in the tracheal lumen: implantation or ectopic?

Objectives:

We report a case of multinodular goitre arising in thyroid tissue within the trachea. This tissue appears to have been implanted at the time of an earlier subtotal thyroidectomy.

Case report:

A 79-year-old woman presented with a 12-month history of dyspnoea. Forty years earlier, she had been treated for a follicular adenoma with subtotal thyroidectomy. Investigation revealed tumour in the region of the right lobe of the thyroid, extending into and narrowing the trachea. A biopsy was performed, and the patient underwent excision of the right thyroid lobe tumour and cricotracheal resection with anastomosis. Histopathological findings were consistent with a multinodular goitre arising in thyroid tissue within the tracheal lumen.

Conclusion:

Intra-operative thyroid tissue implantation in the trachea and subsequent goitre development has not previously been described. This case illustrates the need for careful resection of the thyroid in order to maintain the integrity of normal anatomical structures.

Endoscopic thyroidectomy via breast approach for patients with Graves' disease

BACKGROUND

Endoscopic thyroidectomy via breast approach provides excellent results from a cosmetic viewpoint. We applied this procedure to Graves' disease and evaluated its feasibility and outcomes.

METHODS

From May 2006 to November 2009, a total of 37 patients (34 women and 3 men) with Graves' disease were included in this study. Bilateral subtotal thyroidectomy, which left behind 4-6 g of thyroid remnant, was the standard procedure. For markedly enlarged goiter, fractional resection was performed.

RESULTS

This procedure was performed successfully in all 37 patients. The mean operative time, mean blood loss, and mean excised thyroid weight were 84.7 min, 64 ml, and 51.8 g, respectively. Fractional resection was performed in six cases, where the mean operative time, mean blood loss, and mean excised thyroid weight were 119 min, 138.3 ml, and 102.2 g, respectively. Postoperative transient hypocalcemia occurred in 5 cases (13.5%), and no other complications were noted. The average postoperative hospital stay was 3.4 (range, 3-5) days. One case experienced recurrent hyperthyroidism during a mean follow-up period of 13 months. All patients were satisfied with the cosmetic result of the procedure.

CONCLUSIONS

Endoscopic subtotal thyroidectomy performed via breast approach is a technically feasible and safe procedure with excellent cosmetic results for patients with Graves' disease. In patients with markedly enlarged thyroid glands, subtotal thyroidectomy can be achieved through a fractional resection strategy.

Extrathyroidal implantation of thyroid tumor cells after needle biopsy and other invasive procedures

BACKGROUND

Implantation of thyroid cells (ITC) into extrathyroidal locations is a rare complication of thyroid fine-needle biopsy (FNB) and thyroid surgery. Here we review the prevalence, likely pathogenesis, treatment, and likely ways to minimize this complication of invasive thyroid procedures and present an illustrative patient.

SUMMARY

Tumor aggressiveness more likely leads to ITC after FNB. Large needle size may be associated with increased risk of ITC. Number of passages during biopsy, excessive suction, needle withdrawal without releasing suction, and injection of tumor cells during biopsy may be associated with ITC after FNB. This statement is based on rational hypotheses. Cutting or rupture of a thyroid nodule during surgery leads to ITC into extrathyroidal soft tissue.

CONCLUSIONS

ITC occurs rarely with needles smaller than 23 gauge. Some authorities suggest the use of gentle suction and release suction during extraction and a reduced number of passes based on entirely theoretical grounds. In conventional surgery, lobectomy for all thyroid nodules rather than nodulectomy or partial lobectomy should be performed. If endoscopic surgery is performed on larger nodules, the surgeon should take great care to avoid rupturing the tumor.