The time point of completion thyroidectomy has no prognostic impact in patients with differentiated thyroid cancer

[Frozen section in oncologic endocrine surgery]

BACKGROUND

The aim of the present study is to discuss the benefits of intraoperative frozen sections (FS) for the surgical management of endocrine tumors.

METHODS

A systematic search of the literature of the last ten years on FS in the field of oncologic endocrine surgery was carried out and a discussion based on the available evidence and experience of the authors is provided.

RESULTS

A group of publications focused on the role of intraoperative FS in thyroid surgery in identifying the malignant potential of thyroid nodules. The detection of lymph node metastasis and extrathyroidal growth in differentiated thyroid cancer (DTC) were also two other topical groups as well as the diagnosis of lymph node involvement based on stromal desmoplasia in medullary thyroid cancer (MTC). A further group investigated the possibilities of deep learning to overcome technical problems and another investigated the cost-benefit analyses. There is no relevant literature on the role of FS in the surgical treatment of parathyroid and adrenal cancers.

DISCUSSION

The synthesis of the available evidence suggests that FS investigations of the thyroid glands should be restricted to Bethesda V nodules. The technical limitations in the exclusion of vascular and capsular invasion make the FS unsuitable for follicular neoplasms and oncocytic lesions. The Delphi lymph node seems to be suitable for investigation using FS and when positive represents an indication for lymphadenectomy in cN0 patients. Larger studies are necessary in the future to confirm if the absence of desmoplasia with an intact tumor capsule can reliably justify omitting lymph node resection in MTC, independent of the calcitonin level. The costs and benefits depend on the individual context so that generalization is difficult. Deep learning models could generally improve the performance of FS analysis in the future.

CONCLUSION

In thyroid surgery awareness of the technical limitations of FS is crucial for correct implementation and thus to optimize its performance. A preoperative fine needle biopsy and surgical experience help in selecting the nodules that can benefit from FS. Deep image learning could help to overcome current problems in the future. In adrenal and parathyroid oncologic surgery FS do not play a relevant role.

The learning curve for gasless transaxillary posterior endoscopic thyroidectomy for thyroid cancer: a cumulative sum analysis

Gasless transaxillary posterior endoscopic thyroidectomy (GTPET) is a new approach for thyroid cancer. It allows en bloc resection of the thyroid and central lymph nodes. Few studies have reported on the learning curve for GTPET.We examined the learning curve of GTPET for thyroid cancer by cumulative sum (CUSUM) analysis by retrospectively analyzing patients who underwent hemithyroidectomy with ipsilateral central neck dissection between December 2020 and September 2021 at a tertiary medical center, including the first patient. Moving average analysis and sequential time-block analysis were used for validation. Data on the clinical factors between the two periods were compared. In the overall cohort, the average time for GTPET for thyroid cancer was 113.25 min to harvest an average of 6.4 central lymph nodes. The CUSUM curve of the operative time indicated an inflection point after 38 patients. Moving average analysis and sequential time-block analysis validated the number of procedures needed for GTPET proficiency. (124.05 min vs. 107.63 min for the unproficient period vs. proficient period, respectively; P < 0.001) The number of retrieved lymph nodes was not associated with a certain level of proficiency per the learning curve. The main complication during the surgeon's unproficient period was transient hoarseness (3/38), which was similar to that in their proficient period (2/73, p = 0.336). Proficiency in GTPET is associated with performing more than 38 procedures. Standard course training and instruction on careful management are required prior to introducing the procedure.

Shared Decision Making for Radioiodine Therapy and the Actual Pattern of Care in Intermediate-Risk Differentiated Thyroid Carcinoma

Radioiodine therapy (RAI) is usually a standard procedure performed after thyroidectomy in differentiated thyroid cancer (DTC). While the indication for RAI in high-risk patients has been established in various national and international guidelines, there is an ongoing discussion with regard to intermediate-risk patients. In addition to the inconsistent definition of this risk category, the absence of large multinational prospective randomized controlled trials forms the basis of the debate. In this context, the actual pattern of care and national guidelines in the country where the patient is living plays an important role with respect to regional iodine supply and goiter prevalence, preoperative diagnostics (fine needle aspiration biopsy), and corresponding surgical strategies. Participatory decision-making between physician and informed patient, which is demanded in principle today anyway, is of particular importance in this situation. This article will discuss the approach of shared decision making for radioiodine therapy in intermediate-risk DTC.

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.

[Completion thyroidectomy after less than total resection for postoperatively diagnosed follicular thyroid cancer]

As there are no reliable preoperative or intraoperative markers to identify follicular thyroid cancer (FTC), the postoperative histopathological diagnosis frequently raises the question of completion surgery. The oncological necessity must not be questioned by an allegedly increased morbidity. The operation is particularly indicated if there is evidence of distant or lymph node metastasis, the presence of a broadly invasive FTC, or evidence of extensive angioinvasion. Prophylactic lymphadenectomy is not indicated. There are no clear data that minimally invasive oncocytic FTC poses a special risk. Risk factors such as tumor size and age must be assessed as a biological continuum and require an individual assessment. Utilizing the technical options and thorough planning enables a completion thyroidectomy to be performed without increased risk.