Role of prophylactic central compartment lymph node dissection in clinically N0 differentiated thyroid cancer patients: analysis of risk factors and review of modern trends

Machine learning algorithms for identifying contralateral central lymph node metastasis in unilateral cN0 papillary thyroid cancer

Purpose

The incidence of thyroid cancer is growing fast and surgery is the most significant treatment of it. For patients with unilateral cN0 papillary thyroid cancer whether to dissect contralateral central lymph node is still under debating. Here, we aim to provide a machine learning based prediction model of contralateral central lymph node metastasis using demographic and clinical data.

Methods

2225 patients with unilateral cN0 papillary thyroid cancer from Wuhan Union Hospital were retrospectively studied. Clinical and pathological features were compared between patients with contralateral central lymph node metastasis and without. Six machine learning models were constructed based on these patients and compared using accuracy, sensitivity, specificity, area under the receiver operating characteristic and decision curve analysis. The selected models were then verified using data from Differentiated Thyroid Cancer in China study. All statistical analysis and model construction were performed by R software.

Results

Male, maximum diameter larger than 1cm, multifocality, ipsilateral central lymph node metastasis and younger than 50 years were independent risk factors of contralateral central lymph node metastasis. Random forest model performed better than others, and were verified in external validation cohort. A web calculator was constructed.

Conclusions

Gender, maximum diameter, multifocality, ipsilateral central lymph node metastasis and age should be considered for contralateral central lymph node dissection. The web calculator based on random forest model may be helpful in clinical decision.

Artificial intelligence in the diagnosis of thyroid cancer: Recent advances and future directions

The diagnosis and management of thyroid cancer is fraught with challenges despite the advent of innovative diagnostic, surgical, and chemotherapeutic modalities. Challenges like inaccuracy in prognostication, uncertainty in cytopathological diagnosis, trouble in differentiating follicular neoplasms, intra-observer and inter-observer variability on ultrasound imaging preclude personalised treatment in thyroid cancer. Artificial intelligence (AI) is bringing a paradigm shift to the healthcare, powered by quick advancement of the analytic techniques. Several recent studies have shown remarkable progress in thyroid cancer diagnostics based on AI-assisted algorithms. Application of AI techniques in thyroid ultrasonography and cytopathology have shown remarkable impro-vement in sensitivity and specificity over the traditional diagnostic modalities. AI has also been explored in the development of treatment algorithms for indeterminate nodules and for prognostication in the patients with thyroid cancer. The benefits of high repeatability and straightforward implementation of AI in the management of thyroid cancer suggest that it holds promise for clinical application. Limited clinical experience and lack of prospective validation studies remain the biggest drawbacks. Developing verified and trustworthy algorithms after extensive testing and validation using prospective, multi-centre trials is crucial for the future use of AI in the pipeline of precision medicine in the management of thyroid cancer.

Preoperative strain ultrasound elastography can predict occult central cervical lymph node metastasis in papillary thyroid cancer: a single-center retrospective study

Objective

To determine whether preoperative ultrasound elastography can predict occult central cervical lymph node metastasis (CCLNM) in patients with papillary thyroid cancer.

Methods

This retrospective study included 541 papillary thyroid cancer patients with clinically negative lymph nodes prior to surgery between July 2019 and December 2021. Based on whether CCLNM was present on postoperative pathology, patients were categorized as CCLNM (+) or CCLNM (-). Preoperative clinical data, conventional ultrasound features, and ultrasound elastography indices were compared between the groups. Univariate and multivariate logistic regression analysis were performed to identify the independent predictors of occult CCLNM.

Results

A total of 36.60% (198/541) patients had confirmed CCLNM, while 63.40% (343/541) did not. Tumor location, bilaterality, multifocality, echogenicity, margin, shape, vascularity, capsule contact, extrathyroidal extension, aspect ratio, and shear wave elasticity parameters were comparable between the groups (all P > 0.05). Univariate analysis showed statistically significant differences between the two groups in age, sex, tumor size, calcification, capsule invasion, and strain rates ratio in strain ultrasound elastography (all P < 0.05). In multivariate logistic regression analysis, the independent predictors of occult CCLNM were age (OR = 0.975, 95% CI = 0.959-0.991, P = 0.002), sex (OR = 1.886, 95% CI = 1.220-2.915, P = 0.004), tumor size (OR = 1.054, 95% CI = 1.014-1.097, P = 0.008), and strain rates ratio (OR = 1.178, 95% CI = 1.065-1.304, P = 0.002).

Conclusion

Preoperative strain ultrasound elastography can predict presence of occult CCLNM in papillary thyroid cancer patients and help clinicians select the appropriate treatment strategy.

Ultrasonic Characteristics Improve Prediction of Central Lymph Node Metastasis in cN0 Unifocal Papillary Thyroid Cancer

BACKGROUND

Prediction of central lymph node metastasis (CLNM) is vital for clinical decision-making processes in clinically N0 (cN0) unifocal papillary thyroid carcinoma (PTC), but the sensitivity of preoperative detection of CLNM is limited. The aim of the present study was to determine whether there are ultrasonic (US) characteristics associated with CLNM.

METHODS

In total, 1657 PTC patients (514 men and 1143 women) were enrolled in the present study between January 2018 and May 2021. The patients met the following inclusion criteria based on preoperative detection: suspected nodule confirmed as PTC by biopsy; the nodule was unifocal and less than 4 cm in diameter; no prior neck radiation exposure; no extrathyroidal extension; and no CLNM or distant metastases on imaging. All the enrolled patients underwent total thyroidectomy with prophylactic central lymph node dissection (CLND). A postoperative pathological diagnosis was made.

RESULTS

CLNM was found in 58.4% of male patients and 36.9% of female patients. In univariate analysis, size, adjacent anterior capsule, distance to the lower pole and color Doppler flow imaging (CDFI) were considered risk factors for the male and female groups (p < 0.05). In multivariate analyses, size, adjacent anterior capsule, distance to the lower pole and CDFI were independent risk factors for male patients. For females, the independent risk factors included size, adjacent anterior capsule, distance to the lower pole and CDFI.

CONCLUSION

In the present cohort, US imaging characteristics, including size, adjacent anterior capsule, distance to the lower pole and CDFI, were identified to be potentially beneficial in preoperative clinical decision-making processes for cN0 unifocal PTC patients.

Pattern and Predictive Factors of Metastasis in Lymph Nodes Posterior to the Right Recurrent Laryngeal Nerve in Papillary Thyroid Carcinoma

OBJECTIVE

The right cervical central lymph nodes include lymph nodes anterior to the right recurrent laryngeal nerve (LN-arRLN) and lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN), and are separated by the right recurrent laryngeal nerve (RLN). LN-prRLN is a common site of nodal recurrence after the resection of papillary thyroid carcinoma (PTC). However, the complexity in anatomical structure brings difficulties in determining the surgical scope, so it is necessary to assess the pattern and predictive factors of right cervical central lymph nodes, especially LN-prRLN metastasis in papillary thyroid carcinoma.

METHODS

A total of 562 diagnosed PTC patients who underwent right or total thyroidectomy were enrolled in this retrospective study. The clinicopathological features were collected, univariate and multivariate analyses were performed to determine predictive factors of the right central lymph node metastasis.

RESULTS

In this study, the metastatic rates of the right CLN, the LN-arRLN and the LN-prRLN were 59.6% (335/562), 51.8% (291/562) and 30.4% (171/562), respectively. And 22.6% (127/562) of patients had both LN-arRLN and LN-prRLN metastasis. Among patients without LN-arRLN metastasis, the rate of LN-prRLN metastasis was 16.2% (44/271), accounting for 25.7% of the LN-prRLN metastasis group. Factors associated with an increased risk of LN-arRLN metastasis include male, age below 55 years, tumor size > 1cm, extrathyroidal extension (ETE), clinical lymph nodes metastasis(cN1), lateral lymph node metastasis, and left CLN metastasis. In addition, ETE, lateral lymph node metastasis, and LN-arRLN metastasis were independent factors of LN-prRLN metastasis. The predictive factors of LN-prRLN in cN0 PTC were further explored, revealing that tumor size ≥1.5cm, ETE, and LN-arRLN metastasis were independent predictors of LN-prRLN metastasis in cN0 PTC.

CONCLUSION

The LN-prRLN should not be ignored in surgery because of its high rate of metastasis. Our findings indicate that thorough dissection of central lymph nodes, especially LN-prRLN is crucial in clinical work.

The effectiveness and safety of prophylactic central neck dissection in clinically node-negative papillary thyroid carcinoma patients: A meta-analysis

OBJECTIVE

This meta-analysis was performed to evaluate the effectiveness and safety of prophylactic central neck dissection (PCND) in patients with clinically node-negative (cN0) papillary thyroid carcinoma.

MATERIALS AND METHODS

A meta-analysis of the literature was performed using the key words "papillary thyroid carcinomas" and "lymph node ecisions" for searches of electronic databases. Complications such as transient hypocalcemia, permanent hypocalcemia, transient and permanent hypoparathyroidism, transient and permanent vocal cord paralysis, transient recurrent and permanent recurrent laryngeal nerve injury, and local recurrence were pooled by meta-analysis. Stata17.0 was used to carry out the meta-analysis.

RESULTS

Data were extracted from 15 studies. In the present review, the group of patients who had total thyroidectomy (TT) with PCND had a lower local recurrence than the group with TT alone (OR 0.22, 95% CI 0.10-0.45, P = 0.000), whereas the incidence of permanent hypocalcemia (OR 4.24, 95% CI 1.05-17.22, P = 0.043) and transient hypoparathyroidism (OR 2.14, 95% CI 1.34-3.42, P =0.001) were higher. No significant differences were recorded in the incidence of other complications: transient hypocalcemia (OR 2.24, 95% CI 0.77-6.51, P = 0.138), permanent hypoparathyroidism (OR 1.70, 95% CI 0.89-3.27, P = 0.111), transient vocal cord paralysis (OR 1.48, 95% CI 0.78-2.83, P = 0.231), permanent vocal cord paralysis (OR 1.44, 95% CI 0.53-3.94, P = 0.477), transient recurrent laryngeal nerve injury (OR 1.47, 95% CI 0.93-2.32, P = 0.102) and permanent recurrent laryngeal nerve injury (OR 1.24, 95% CI 0.56-2.74, P = 0.587) between the two groups.

CONCLUSION

Compared with TT alone, TT with PCND was more effective in reducing local recurrence without increasing the risk of recurrent laryngeal nerve, thyroid and vocal cord, except for hypocalcemia and transient hypoparathyroidism. Therefore, we believe that TT with PCND should be recommended for patients with cN0 PTC.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD4202 2355078.

BRAFV600E mutation test on fine-needle aspiration specimens of thyroid nodules: Clinical correlations for 4600 patients

Background

The BRAF^V600E mutation is valuable for the diagnosis, prognosis, and therapy of papillary thyroid cancer (PTC). However, studies related to this mutation have involved only a small number of patients. Therefore, we performed a large‐scale analysis from a single institute to evaluate the accuracy of combined fine‐needle aspiration (FNA) and BRAF^V600E mutation tests for PTC diagnosis.

Methods

A total of 4600 patients with thyroid nodules who underwent both FNA cytology and BRAF^V600E mutation analysis on FNA specimens were enrolled. The association between the BRAF^V600E mutation and clinicopathological features was analyzed. A separate analysis was performed for the 311 patients who underwent repeated FNA for comparison of cytological evaluation and BRAF^V600E mutation results. The diagnostic efficacy of the BRAF^V600E mutation test and cytologic diagnoses was evaluated for 516 patients who underwent preoperative FNA tests in comparison with conclusive postoperative histopathologic results.

Results

The cytology results of all 4600 FNA samples were categorized according to The Bethesda System for Reporting Thyroid Cytology (TBSRTC) stages I–VI, which accounted for 11.76%, 60.02%, 6.46%, 3.61%, 6.71%, and 11.43% of the samples, respectively. The BRAF^V600E mutation was detected in 762 (16.57%) FNA samples, with rates of 1.48%, 0.87%, 20.20%, 3.01%, 66.02%, and 87.81% for TBSRTC I–VI lesions, respectively. Among the 311 repeat FNA cases, 81.0% of the BRAF^V600E‐positive and 4.3% of the BRAF^V600E‐negative specimens with an initial indication of cytological non‐malignancy were ultimately diagnosed as malignant by repeat FNA (p < 0.001). Among the 516 patients who underwent thyroidectomy, the sensitivity and specificity of the BRAF^V600E mutation test alone for PTC diagnosis were 76.71% and 100.0%, respectively, which increased to 96.62% and 88.03%, respectively, when combining the BRAF^V600E mutation test with cytology. BRAF^V600E mutation was significantly associated with lymph node metastasis (p < 0.001), but not with age, gender, or tumor size.

Conclusions

The BRAF^V600E mutation test in FNA samples has potential to reduce false negatives in PTC diagnosis, and therefore plays an important role in the diagnosis of thyroid nodules, especially those with an indeterminate or nondiagnostic cytology, which should be considered for repeat FNA.

Clinical Study of Virtual Reality Augmented Technology Combined with Contrast-Enhanced Ultrasound in the Assessment of Thyroid Cancer

Thyroid cancer has become the most common malignant tumor in the endocrine system, and its global incidence has been showing an upward trend. The diagnosis methods of thyroid cancer include ultrasound, fine-needle aspiration cytology, and neck CT, but the single ultrasound feature cannot simultaneously take into account the sensitivity and specificity of more than 85% when diagnosing thyroid cancer. The development of virtual technology can significantly improve the diagnosis of the thyroid gland. Based on this, this article proposes a clinical study of virtual reality technology combined with contrast-enhanced ultrasound in the assessment of thyroid cancer. This article uses a variety of methods, such as literature method, mathematical statistics, and experimental research, in-depth study of the theoretical cornerstones of virtual reality augmented technology, the application status of ultrasound contrast technology, and so on. And a fuzzy mean clustering algorithm was proposed to identify ultrasound images. Then, a clinical experiment of virtual reality augmented technology combined with contrast-enhanced ultrasound was designed to evaluate thyroid cancer, which included comparison of contrast-enhanced ultrasound signs, analysis of enhancement results, multifactor logistic analysis, and diagnostic efficacy analysis of ultrasound signs. The combined application of virtual reality augmented technology and contrast-enhanced ultrasound in the study of thyroid cancer has a sensitivity and specificity exceeding 85% as the diagnosis boundary changes, and the accuracy of the combined diagnosis is relatively high.

Preoperative prediction of lymph node metastasis in patients with papillary thyroid carcinoma by an artificial intelligence algorithm

BACKGROUND

It is necessary to identify patients at risk of developing lymph node metastasis prior to papillary thyroid carcinoma (PTC) surgery. This can be challenging due to limiting factors, and an artificial intelligence algorithm may be a viable option.

OBJECTIVE

In this study, we aimed to evaluate whether combining an artificial intelligence algorithm (support vector machine and probabilistic neural network) and clinico-pathologic data can preoperatively predict lymph node metastasis of papillary thyroid carcinoma (PTC).

METHODS

We retrospectively examined 251 PTCs with lymph node metastasis and 194 PTCs without lymph node metastasis. The artificial intelligence algorithm included the support vector machine (SVM) and the probabilistic neural network (PNN).

RESULTS

The ACR TI-RADS (Thyroid Imaging, Reporting and Data System), number of tumours, no well-defined margin, lymph node status and rim calcification on ultrasonography (US), age, sex, tumour size, and presence of Hashimoto's thyroiditis were significantly more frequent among PTCs with central lymph node metastasis than those without metastasis (P<0.05). The PNN classifier revealed an F1 score of 0.88 on the central lymph node metastasis test set. The SVM classifier revealed an F1 score of 0.93 on the lateral lymph node metastasis test set. Our study demonstrates that combining artificial intelligence algorithms and clinico-pathologic data can effectively predict the lymph node metastasis of papillary thyroid carcinoma prior to surgery.

The Clinical Significance of Lymph Node Ratio and Ki-67 Expression in Papillary Thyroid Cancer

BACKGROUND

The N stage in papillary thyroid cancer (PTC) is an important prognostic factor based on anatomical localization of cervical lymph nodes (LNs) only and not the extent of lymphatic metastasis. In this retrospective study, the clinical significance of lymph node ratio (LNR) and tumor cell proliferation in relation to the conventional classification of PTC was explored.

METHODS

Patients diagnosed with PTC at the Karolinska University Hospital in Stockholm, Sweden, during the years 2009-2011 were included. The LNR, defined as the number of metastatic LNs divided by the total number of LNs investigated, and the Ki-67 index were analyzed in relation to clinical data.

RESULTS

The median number of LN removed was 16 with the following N stage distribution: N0 (26%), N1a (45%), and N1b (29%). A Ki-67 index of ≥3% was significantly correlated with the presence of metastases and tumor recurrence with a sensitivity of 50% and specificity of 80% (p = 0.015). Lymph node ratio ≥21% was related to tumor recurrence with sensitivity of 89% and specificity of 70% (p = 0.006). Patients with LN metastases in the lateral cervical compartment only had significantly lower LNR (14.5%) compared to those with both central and lateral cervical metastases (39.5%) (p = 0.004) and exhibited no tumor recurrence. Increased Ki-67 index was significantly related to LNR ≥21% (p = 0.023) but was not associated with N stage.

CONCLUSIONS

The Ki-67 proliferation index and LNR may better reflect the malignant behavior of PTC compared to the anatomical classification of LN metastases solely.

Metastasis of cN0 Papillary Thyroid Carcinoma of the Isthmus to the Lymph Node Posterior to the Right Recurrent Laryngeal Nerve

OBJECTIVE

The association between metastasis to the lymph node posterior to the right recurrent laryngeal nerve (LN-prRLN) and cN0 papillary thyroid carcinoma (PTC) located in the thyroid isthmus remains unknown; therefore, our goal was to analyze the characteristics of LN-prRLN metastasis of cN0 PTCs of the thyroid isthmus and determine its potential predictors.

PATIENTS AND METHODS

This retrospective study included patients who underwent bilateral central neck dissection between January 2018 and January 2021. The specimen was divided into five groups of prelaryngeal lymph node (LN), pretracheal LN, left paratracheal LN, lymph node anterior to the right recurrent laryngeal nerve (LN-arRLN), and LN-prRLN. Univariate and multivariate analyses were used to assess the association between the clinical pathologic variables and LN-prRLN metastases. Surgical complications were presented descriptively.

RESULTS

A total of 357 patients were included, LN-prRLN metastasis occurred in 23 (6.4%) patients, and LN-prRLN was positive only when there were other LN metastases, especially LN-arRLN metastases. Other independent risk factors for LN-prRLN included foci numbers ≥2, tumor size ≥5.0 mm, and extrathyroidal extensions. The rates of permanent hypoparathyroidism and vocal cord paralysis were 1.1% and 2.0%, respectively.

CONCLUSION

LN-prRLN metastases should not be ignored in cN0 PTC located in the thyroid isthmus; however, its dissection is a safe procedure, and the status of LN-arRLN can be a reliable predictor for LN-prRLN metastases.

An Ultrasound Radiomics Nomogram for Preoperative Prediction of Central Neck Lymph Node Metastasis in Papillary Thyroid Carcinoma

Purpose: This study aimed to establish and validate an ultrasound radiomics nomogram for the preoperative prediction of central lymph node (LN) metastasis in patients with papillary thyroid carcinoma (PTC).

Patients and Methods: The prediction model was developed in 609 patients with clinicopathologically confirmed unifocal PTC who received ultrasonography between Jan 2018 and June 2018. Radiomic features were extracted after the ultrasonography of PTC. Lasso regression model was used for data dimensionality reduction, feature selection, and radiomics signature building. The predicting model was established based on the multivariable logistic regression analysis in which the radiomics signature, ultrasonography-reported LN status, and independent clinicopathologic risk factors were incorporated, and finally a radiomics nomogram was established. The performance of the nomogram was assessed with respect to the discrimination and consistence. An independent validation was performed in 326 consecutive patients from July 2018 to Sep 2018.

Results: The radiomics signature consisted of 23 selected features and was significantly associated with LN status in both primary and validation cohorts. The independent predictors in the radiomics nomogram included the radiomics signature, age, TG level, TPOAB level, and ultrasonography-reported LN status. The model showed good discrimination and consistence in both cohorts: C-index of 0.816 (95% CI, 0.808–0.824) in the primary cohort and 0.858 (95% CI, 0.849–0.867) in the validation cohort. The area under receiver operating curve was 0.858. In the validation cohort, the accuracy, sensitivity, specificity and AUC of this model were 0.812, 0.816, 0.810, and 0.858 (95% CI, 0.785–0.930), respectively. Decision curve analysis indicated the radiomics nomogram was clinically useful.

Conclusion: This study presents a convenient, clinically useful ultrasound radiomics nomogram that can be used for the pre-operative individualized prediction of central LN metastasis in patients with PTC.

Papillary thyroid carcinoma: an ultrasound-based nomogram improves the prediction of lymph node metastases in the central compartment

OBJECTIVES

To develop a nomogram based on postoperative clinical and ultrasound findings to quantify the probability of central compartment lymph node metastases (CLNM).

METHODS

A total of 952 patients with histologically confirmed papillary thyroid carcinoma (PTC) were included in this retrospective study and assigned to three groups based on sex and age. The strongest predictors for CLNM were selected according to ultrasound imaging features, and an ultrasound (US) signature was constructed. By incorporating clinical characteristics, a predictive model presented as a nomogram was developed, and its performance was assessed with respect to calibration, discrimination and clinical usefulness.

RESULTS

Predictors contained in the nomogram included US signature, US-reported LN status and age. The US signature was constructed with tumour size and microcalcification. The nomogram showed excellent calibration in the training dataset, with an AUC of 0.826 (95% CI, 0.765-0.887) for male patients, 0.818 (95% CI, 0.746-0.890) for young females and 0.808 (95% CI, 0.757-0.859) for elder females. For male and young female patients, application of the nomogram to the validation cohort revealed good discrimination, with AUCs of 0.813 (95% CI, 0.722-0.904) and 0.814 (95% CI, 0.712-0.915), respectively. Conversely, for elderly female patients, the nomogram failed to show good performance with an AUC of 0.742 (95% CI, 0.661-0.823).

CONCLUSION

This ultrasound-based nomogram may serve as a useful clinical tool to provide valuable information for treatment decisions, especially for male and younger female patients.

KEY POINTS

• Age, gender, US-reported LN status and US signature were the strongest predictors of CLNM in PTC patients and informed the development of a predictive nomogram. • Microcalcification was the strongest predictor in the US signature, as CLMN was identified in approximately 92% of patients characterised by diffuse microcalcification. • Stratified by sex and age, this nomogram achieved good performance in predicting CLNM, especially in male and young female patients. This prediction tool may be useful as an imaging marker for identifying CLNM preoperatively in PTC patients and as a guide for personalised treatment.

Role of global aberrant alternative splicing events in papillary thyroid cancer prognosis

BACKGROUND

Alternative splicing events have been increasingly reported for anomalous perturbations in various cancers, including papillary thyroid cancer (PTC).

METHODS

Integration analysis of RNA sequencing and clinical information were utilized to identify survival associated splicing events in PTC. Then, several prognosis-related splicing events were submitted to develop moderate predictors for survival monitoring by using least absolute shrinkage and selection operator model. In addition, several biomedical computational algorithms were conducted to identify pathways enriched by genes with prognostic splicing events and construct regulatory network dominated by splicing factors.

RESULTS

Survival analysis in 496 PTC patients indicated that TNM stage, tumor stage, distant metastasis and tumor status were significantly correlated with PTC patients' progression-free interval. 2799 splicing events were identified as prognostic molecular events. Functional enrichment analysis suggested that prognostic splicing events are associated with several energy metabolism-related processes. Based on these prognostic events, several prognostic signatures were developed. The final prognostic signature acted as an independent prognostic factor after adjusting for several clinical parameters. Interestingly, splicing regulatory network was constructed to display potential regulatory mechanisms of splicing events in PTC.

CONCLUSIONS

Our analysis provides the status of splicing events involved in the progression and may represent an underappreciated hallmark of PTC.

Minimally invasive comprehensive treatment for granulomatous lobular mastitis

Objective

To describe a minimally invasive comprehensive treatment for granulomatous lobular mastitis (GLM) and compare its effect with the existing methods, particularly in terms of its recurrence rate and esthetic outcomes.

Methods

This retrospective study reviewed 69 GLM patients receiving the minimally invasive comprehensive treatment. Patients’ information, including age, clinical features, image characteristics, histopathological findings, mastitis history, treatment process, operative technique, recurrence, and esthetic effect, was evaluated.

Results

All patients were female with a median age of 32 (range 17–55) years. Hospital stays ranged from 2 to 34 days, with a median of 6 days. The shortest time for complete rehabilitation was 2 days and the longest time was 365 days, with a median of 30 days. After a median follow-up of 391 days (range 162–690), 7 patients (10.14%) relapsed. The average cosmetic score was 2.62 ± 0.57 points and was mainly related to the past treatment, especially the surgical history.

Conclusion

Minimally invasive comprehensive treatment is a new method for the treatment of GLM, ensuring a therapeutic effect while maintaining breast beauty.

Effect of prophylactic central neck dissection on the surgical outcomes in papillary thyroid cancer: experience in a single center

PURPOSE

Morbidity due to papillary thyroid carcinoma (PTC) is increased mostly due to lymph node (LN) metastases, which lead to reoperations and complications associated with these operations. The aim is to compare the outcomes of PTC having total thyroidectomy and prophylactic central lymph node dissection (TT + PCND) with patients having total thyroidectomy (TT) alone.

METHODS

This study is a retrospective cohort analysis of 358 PTC patients that were operated by a single surgeon in a single center. Data about the patients were extracted from the medical records.

RESULTS

Of the patient cohort, 258 patients had TT + PCND (42.5 ± 11.3 years) and 100 patients (41.2 ± 11.9 years) had only TT. Total number of LN extracted in the TT + PCND group was 8.1 ± 6.9. The mean number of metastatic LN were 2.2 ± 1.9. Percentage of patients that had RAI were less in the TT + PCND group compared to the TT group. Seven patients (2.7%) in the TT + PCND group and 19 (19.0%) in TT group had recurrent disease (p < 0.0001). Of the complications, only transient hypoparathyroidism was increased in TT + PCND group compared to TT group (26.7% vs 10%, p < 0.0001).

CONCLUSION

TT + PCND performed by an experienced surgeon seems to decrease the number of LN recurrences, and the need for reoperations.

Comparison between Magnification Techniques and Direct Vision in Thyroid Surgery: A Systematic Review and Meta-Analysis

Background and Objectives: The most common complications after conventional thyroid surgery in adult patients are recurrent laryngeal nerve (RLN) injury and hypocalcemia. Magnification techniques (surgical loupes or surgical microscope) are used for identification of RLN and parathyroid glands to diminish these complications although more evidence is necessary to assess their safety and efficacy in comparison with direct vision. Methods and Materials: Electronic databases (Pubmed, Cochrane Library, Scopus) as well as gray literature sources were searched for randomized controlled trials (RCTs) comparing the frequency of transient/permanent RLN injury and hypocalcemia after thyroid surgery by using magnification techniques and direct vision for identification of RLN and parathyroid glands until October 17, 2019. The main outcomes were transient/permanent RLN injury and hypocalcemia. For all outcomes, 95% confidence intervals (95% CI) were used. Statistical analysis was performed with RevMan 5.3. Results: Systematic review and meta-analysis included 3 RCTs with 437 patients overall. Magnification techniques did not significantly affect the risk of occurrence of transient RLN injury (OR = 0.38, 95% CI (0.11-1.35), I² = 0%) and transient hypocalcemia (OR = 0.31, 95% CI (0.09-1.09), I² = 23%) compared with direct vision. Included RCTs demonstrated only two patients with permanent hypocalcemia and another one with permanent RLN injury, who belonged to the direct vision group. Conclusion: The use of magnification techniques for identification of RLN and parathyroid glands seems to be as safe as direct vision. However, they do not decrease the risk of RLN injury and transient hypocalcemia after thyroid surgery compared with direct vision. Finally, further prospective research should be conducted as the sample among the studies was small.

Medullary thyroid carcinoma with double negative calcitonin and CEA: a case report and update of literature review

BACKGROUND

Medullary thyroid carcinoma is a malignant uncommon and aggressive tumour of the parafollicular C cells. In about 75% of cases it is sporadic while, in case of RET mutation, it is associated to multiple endocrine neoplasia type 2 (25% of cases). The biochemical features of medullary thyroid carcinoma include the production of calcitonin and carcinoembryogenic antigen. The above-mentioned features are useful in the diagnostic process as well as in the follow up and in the prognostication of the disease. Even if calcitonin elevation is strongly associated to MTC, it can also be found increased in many pathological different conditions as pregnancy, lactation, C-cells hyperplasia, autoimmune thyroiditis, end stage renal disease, lung and prostate cancer and several neuroendocrine tumours. Major medullary thyroid tumours are usually connected to high doses of circulating calcitonin, in fact non-secretory variants have hardly been described.

CASE PRESENTATION

We herein report the case of a 59 years old male, who had undergone total thyroidectomy for multinodular goiter with negative preoperative calcitonin, showing medullary thyroid carcinoma at definitive pathology. To the best of our knowledge, this is the first case documenting a non-secretory medullary thyroid carcinoma, with double negative markers at the time of diagnosis and at the relapse.

CONCLUSION

A Literature review underlining pathological hypothesis, differential diagnosis and alternative and innovative biomarkers to identify non-secretory medullary thyroid carcinoma was carried out.

Age, thyroglobulin levels and ATA risk stratification predict 10-year survival rate of differentiated thyroid cancer patients

INTRODUCTION

Differentiated thyroid cancer (DTC) is the most common of endocrine cancers. Many studies have focused on recurrence-free survival of DTC patients, however, few studies have addressed overall survival rates. Given its very good prognosis, estimating overall or long-term survival in patients with DTC seems rational. So far, neither the impact of pre- and post-ablation thyroglobulin, nor that of initial American Thyroid Association (ATA) risk stratification on long-term disease-specific survival, have been sufficiently studied.

OBJECTIVE

The aim of this study was to determine the factors that influence long-term disease-specific survival and thyroglobulin levels in patients with DTC who have been previously treated with thyroidectomy and radioactive iodine (RAI) remnant ablation.

PATIENTS AND METHODS

This observational retrospective study included 1093 patients who were treated for DTC between 1995 and 2010 and are still monitored in our tertiary center. Only patients who needed RAI ablation after thyroidectomy were included in this study. Patients who were treated with RAI following rhTSH stimulation, patients who presented positive anti-thyroglobulin antibodies, and patients who had micro-cancers were excluded. Pre-ablation stimulated thyroglobulin (Pre-ablation sTg) was measured after thyroid hormone withdrawal (THW), just before RAI.

RESULTS

According to ATA standards, 29 patients (2.7%) were classified as high-risk patients. Initial ATA high-recurrence risk rating (HR 21.9; 95% CI: 8.5-56.3), age>55 years (HR 23.8; 95%-CI: 7.5-75.3) and pre-ablation sTg≥30 μg/l (HR 8.4; 95% CI: 4.6-15.3) significantly impacted ten-year survival. Moreover, age over 45 years, ATA moderate-risk and follicular DTC were also significant. Ten-year survival was lower in ATA high-risk patients (51% vs 95% and 93% for the low and intermediate risk; p<10-7), patients older than 55 years (82% vs 98%; p<10-7), and in patients with pre-ablation sTg≥30 (78% vs 95%; p<10-7). Three rates of long-term survival were distinguished: excellent (survival rate of 99% in patients<55 years with pre-ablation sTg <30μg/l) representing 59% of the cohort, moderate (survival rate of 94.5% in patients <55 years with pre-ablation sTg ≥30μg/l or ≥55 years with pre-ablation sTg <30 μg/l) representing 38% of the cohort, and low (survival rate of 49% in patients ≥55 years with pre-ablation sTg ≥30μg/l) representing 3% of the cohort.

CONCLUSION

Initial ATA high-risk classification, age over 55 years old and pre-ablation sTg ≥30 μg/l are the main negative factors that influence the ten-year survival in DTC. We suggest three categories of overall survival rates. Patients older than 55 years with pre-ablation sTg ≥30 μg/l have the worst survival rate.

Correlation between iPTH Levels on the First Postoperative Day After Total Thyroidectomy and Permanent Hypoparathyroidism: Our Experience

Permanent hypoparathyroidism is the most common long-term complication after thyroidectomy. We evaluated whether iPTH concentrations on the first postoperative day may be a good predictor of this complication.

Patients undergoing thyroidectomy in our Unit between January 2017 and February 2018 who developed postsurgical hypoparathyroidism were analysed. According to iPTH values on the first postoperative day and on the basis of the detection threshold of the iPTH test used, patients were divided into 2 groups: Group A (iPTH < 6.3 pg/mL, undetectable), Group B (iPTH ≥ 6.3 pg/mL).

Seventy-five patients were included in this study: 64 in Group A and 11 in Group B. Permanent hypoparathyroidism occurred in 14 (21.88%) patients in Group A, while none developed this complication in Group B. When iPTH was < 6.3 pg/mL, the sensitivity for the prediction of permanent hypoparathyroidism was 100%, the specificity was 18.03%, the positive predictive value was 21.88% and the negative predictive value was 100%.

No patient with iPTH ≥ 6.3 pg/mL on the first postoperative day developed permanent hypoparathyroidism. On the other hand, iPTH concentrations < 6.3 pg/mL have not proved to be a strong predictor of this condition. However, this cut-off value can be useful to identify patients at risk of developing this complication.

Calcitonin negative Medullary Thyroid Carcinoma: a challenging diagnosis or a medical dilemma?

BACKGROUND

Medullary thyroid carcinoma is a neuroendocrine tumor belonging form a malignant growth of the thyroid parafollicular C-cells, representing from 1 to 10% of all thyroid cancer. The biochemical activity of medullary thyroid carcinoma includes the production of calcitonin and carcinoembryogenic antigen, which are sensitive tumor markers, facilitating the diagnosis, follow-up and prognostication. The diagnosis is reached through the identification of high basal calcitonin serum level or after pentagastrin stimulation test. Medullary thyroid carcinoma is able to produce other relevant biomarkers as procalcitonin, carcinoembryionic antigen and chromogranin A. In Literature are described few cases of medullary thyroid carcinoma without elevation of serum calcitonin, an extremely rare event. The aim of this study was to analyse the presentation, the main features and therapeutic management of medullary thyroid carcinoma associated with negative serum calcitonin levels.

METHODS

Using the PubMed database, a systematic review of the current Literature was carried out, up to February 2018. Finally, nineteen articles met our inclusion criteria and were selected according to the modified Newcastle-Ottawa scale.

RESULTS

Fourty-nine patients with definitive pathology confirming medullary thyroid carcinoma and with calcitonin serum level in the normal range were identified (24 female, 24 male and not reported gender in 1 case). Mean age was 51.7 years. Serum calcitonin levels were reported for 20 patients with a mean value of 8.66 pg/mL and a range of 0.8-38 pg/mL. Despite the low or undetectable calcitonin serum level, at immunochemistry in almost the half of the cases reported by the Authors, the tumors presented diffuse or focal positivity for calcitonin and carcinoembryionic antigen, while was reported a chromogranin A positivity in 41 of the 43 tested patients.

CONCLUSIONS

Calcitonin negative medullary thyroid carcinoma is an extremely rare pathology. The diagnosis and the surveillance is often challenging and delayed, due to the lack of elevation of serum markers as calcitonin and carcinoembryionic antigen. Further studies are needed, to better define options for management of non secretory medullary thyroid carcinoma and to identify new and reliable biomarkers associated to diagnosis and relapse of this medical dilemma.

The role of prophylactic central compartment lymph node dissection in elderly patients with differentiated thyroid cancer: a multicentric study

BACKGROUND

Prophylactic central neck lymph-nodes dissection is still a topic of major debate in Literature. There is a lack of randomized controlled trials proving advantages in its application in terms of overall survival and local recurrence. Due to the recent rapid increase of elderly population, differentiated tumor carcinoma diagnosis increased in patients over 65 years old. The aim of this study was to compare recurrence rate, complications rate and histological features of tumors in elderly population.

METHODS

A retrospective study was carried out collecting data from 371 patients with differentiated thyroid cancer without clinical evidence of lymph-nodes involvement in three Italian referral centers from 2005 to 2015. All patients were aged ≥ 65 years and were divided in two groups based on the performed surgery (total thyroidectomy alone or associated with central lymph-nodes dissection). Moreover, patients were stratified according to the age between 65 and 74 years old and over 75 years old.

RESULTS

Total thyroidectomy alone was performed in 184 patients (group A) and total thyroidectomy with prophylactic central neck dissection was performed in 187 cases (group B). There was a statistically significant difference in complications between the groups in terms of neck hematoma (0.5% group A vs 3.7% group B), temporary hypoparathyroidism (11.4% group A vs 21.4% group B), and temporary unilateral recurrent nerve injury (1.5% group A vs 6.4% group B). Lymph nodes recurrence rate was 9.2% in group A and 8.5% in group B, with no statistically significant difference. There was a statistically significant difference in patients over 75 years old in terms of temporary hypoparathyroidism (24% group A vs 11% group B), permanent hypoparathyroidism (2,7% group A vs 0,3% group B) and recurrent nerve injury (9,5% group A vs 2% group B).

CONCLUSIONS

The role of prophylactic central neck dissection is still controversial, especially in elderly patients, and an aggressive surgical approach should be carefully evaluated. The Authors reported a similar low recurrence rate between total thyroidectomy and total thyroidectomy associated with prophylactic central neck dissection, with increased postoperative complications in the lymphadenectomy group and in patients over 75 years old, advocating a tailored surgical approach in elderly population.

Carbon nanoparticle lymph node tracer improves the outcomes of surgical treatment in papillary thyroid cancer

BACKGROUND

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy which is generally accompanied by lymph node metastasis.

OBJECTIVE

Our study evaluated whether carbon nanoparticle lymph node tracer can improve the outcomes of surgical treatment in papillary thyroid cancer (PTC).

METHODS

Ninety-two patients were selected and underwent total thyroidectomy and lymph node resection. Our study placed 45 individuals into the treatment group (carbon nanoparticle group) and 47 cohorts in the control group (no carbon nanoparticle group).

RESULTS

Carbon nanoparticle application remarkably improved lymph nodes detection rate in patients (4.7 ± 3.0; P< 0.05) compared to those in control groups (3.5 ± 2.3). The rate of parathyroid accidental resection in the carbon nanoparticle group significantly decreased (6.67%) compared to the control group (21.28%). Incidents of hypoparathyroidism and hypocalcaemia significantly decreased among the carbon nanoparticle cohorts.

CONCLUSIONS

Our study definitively showed that carbon nanoparticles can be used to effectively treat lymphatic carcinoma. Our study presented clinical evidences for potential application of carbon nanoparticle in improving the management of PTC patients.

Ultrasound-guided fine-needle aspiration biopsy of thyroid nodules <10 mm in the maximum diameter: does size matter?

Objective

Ultrasound-guided fine-needle aspiration biopsy (US-FNAB) is a safe and effective method of screening malignant thyroid nodules such as papillary thyroid carcinoma. However, not much data are available regarding the diagnostic efficacy of US-FNAB for papillary thyroid microcarcinoma (≤10 mm in diameter). We aim to compare the diagnostic efficacy of US-FNAB on thyroid nodules between two groups divided by a diameter of 10 mm by correlating the cytological results of US-FNAB with the histopathologic diagnoses in selected patients.

Patients and methods

Eight hundred twenty-two thyroid nodules (Group A: diameter ≤10 mm, n=620; Group B: diameter >10 mm, n=202) from 797 patients treated between March 2014 and June 2017 were retrospectively evaluated. Only nodules with Thyroid Imaging Reporting and Data System (TIRADS) categories 4–6 were enrolled and sampled by US-FNAB, followed by surgical resection.

Results

According to The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) diagnostic categories, 94 thyroid nodules were classified as I, III and IV, and were excluded from the analysis. The resultant 728 thyroid nodules from 721 patients were analyzed. The malignant tendency (TBSRTC V and VI) rates on US-FNAB were 88.2% and 84.6% (P=0.202) in Group A and Group B, respectively, and the malignant rates were 89.5% and 86.9% (P=0.330), respectively, on histopathology. There was a high concordance between cytology and histopathology diagnoses (kappa value =0.797), and no statistical difference in terms of US-FNAB accuracy was found between the two groups (P=0.533).

Conclusion

For thyroid nodules of TIRADS category 4–6, the diagnostic efficacy of US-FNAB is similar for thyroid nodules either smaller or greater than 10 mm in their maximum diameter.

Intraoperative carbon nanoparticles mapping in secondary total thyroidectomy for recurrent thyroid nodules: Results of a 8-criterion case-match study (case control study)

BACKGROUND

The extent of total thyroidectomy in the management of multinodular goiter remains unclear. Compared to primary thyroidectomy, secondary total thyroidectomy is more difficult to perform and carries a significantly higher risk of postoperative complications such as recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism. In this study, we aimed to evaluate the efficacy and safety of intraoperative carbon nanoparticle (CN) mapping in patients undergoing secondary total thyroidectomy.

METHODS

We performed a case-matched analysis of a prospectively maintained database using 8 specific criteria to compare perioperative outcomes after primary total thyroidectomy to those after secondary total thyroidectomy with intraoperative CN mapping. The criteria included age, sex, operative procedure, RLN/parathyroid glands (PGs) exploration, preoperative vocal cord calcium abnormalities, and pathological results. Thirty-five patients underwent secondary total thyroidectomy with intraoperative CN mapping due to recurrent thyroid nodules or development of nodules suspicious for malignancy after subtotal thyroidectomy. Fifty exact matches for all 8 criteria were identified from the database in our previous study, which included records of 3078 primary thyroidectomies without CNs. Perioperative outcomes, surgical technique, and complications were analyzed.

RESULTS

The RLNs were successfully identified in all 35 patients. Among three patients that experienced slight hoarseness, one had an RLN end-to-end anastomosis with subsequent improvement in the during the 12-month follow-up period. Two patients experienced changes in vocal tone, but recovered after several months. Two patients underwent parathyroid auto-transplantations, and subsequently presented with transient hypocalcaemia. Their symptoms gradually remitted within one year. Except for mean operation time, there were no statistically significant differences in complications between the primary total thyroidectomies and the secondary total thyroidectomy with CNs.

CONCLUSIONS

Intraoperative CN mapping, expert knowledge of the jugular anatomy, and standardized resection procedures can minimize the incidence of complications such as RLN palsy and hypoparathyroidism after secondary total thyroidectomy.

Risk factors for contralateral central lymph node metastasis in unilateral cN0 papillary thyroid carcinoma: A meta-analysis

BACKGROUND

Central lymph node metastasis(CLNM) is common in papillary thyroid carcinoma(PTC). LNM is related to local recurrence and adverse prognosis. The extent of prophylactic central lymph node dissection(pCLND) is not well defined. We aim to investigate the prevalence and risk factors for contralateral central lymph node metastasis (CCLNM) in unilateral clinical node-negative (cN0) PTC patients to determine the appropriate extent of pCLND.

METHODS

A systematic literature search was performed using PubMed and Embase databases until May 2018. Published studies that estimated the association between clinicopathologic factors and CCLNM were included.

RESULTS

A total of 6 studies involving 1399 patients were included. The prevalence of CCLNM was 10.9% in all patients. The pooled analysis revealed that male gender (pooled OR = 1.67, 95%CI = 1.11-2.53, p = 0.015), age<45years (pooled OR = 1.97, 95%CI = 1.37-2.85, p < 0.001), lymphovasular invasion (pooled OR = 4.23, 95%CI = 2.25-7.98, p < 0.001), extrathyroid invasion (pooled OR = 1.75, 95%CI = 1.08-2.83, p = 0.023), and ipsilateral CLNM (pooled OR = 12.26, 95%CI = 7.27-20.67, p < 0.001) were significant risk factors for CCLNM. While tumor size>1 cm (pooled OR = 3.39, 95%CI = 0.83-13.88, P = 0.090), capsular invasion (pooled OR = 1.28, 95%CI = 0.79-2.06, p = 0.313), extrathyroid extension (pooled OR = 1.49, 95%CI = 0.86-2.56, p = 0.152), and MACIS≥6 (pooled OR = 1.08, 95%CI = 0.51-2.26, p = 0.844) were not significantly associated with CCLNM.

CONCLUSIONS

Our meta-analysis identified that male gender, age<45years, lymphovasular invasion, extrathyroid invasion and ipsilateral CLNM were significant risk factors for CCLNM. These findings may guide the extent of pCLND in unilateral cN0 PTC patients.

Prediction of central lymph node metastasis in papillary thyroid microcarcinoma according to clinicopathologic factors and thyroid nodule sonographic features: a case-control study

Background

Preoperative diagnosis of central lymph node metastasis (CLNM) poses to be a challenge in clinical node-negative papillary thyroid microcarcinoma (PTMC). This research work aims at investigating the association existing between BRAF mutation, clinicopathological factors, ultrasound characteristics, and CLNM, in addition to establishing a predictive model for CLNM in PTMC.

Materials and methods

The study included 673 PTMC patients, already undergone total thyroidectomy or lobectomy with prophylactic central lymph node dissection. The predictor factors were identified through univariate and multivariate analyses. The support vector machine was put to use to develop statistical models, which could predict CLNM on the basis of independent predictors.

Results

Tumor size (>5 mm), lower location, no well-defined margin, contact of >25% with the adjacent capsule, display of enlarged lymph nodes, and BRAF mutation were independent predictors of CLNM. Through the use of the predictive model, 79.6% of the patients were classified accurately, the sensitivity and specificity amounted to be 85.1% and 75.8%, respectively, and the positive predictive value and negative predictive value stood at 71.6% and 87.6%, respectively.

Conclusions

We established a predictive model in order to predict CLNM preoperatively in PTMC when preoperative diagnosis of CLNM was not clear.

Inhibitory roles of miR‑9 on papillary thyroid cancer through targeting BRAF

MicroRNA‑9 (miR‑9) is reported to be underexpressed in papillary thyroid carcinoma (PTC) tissues; however, the molecular mechanisms underlying the implication of miR‑9 in PTC have yet to be elucidated. The present study aimed to explore the potential roles of miR‑9 in PTC. PTC tissue samples and paired non‑cancerous adjacent tissues were collected from 60 patients with PTC. The human TPC‑1 thyroid gland papillary carcinoma cell line was used to investigate the molecular mechanisms underlying the roles of miR‑9 in PTC. The levels of miR‑9 and its downstream target gene BRAF were detected through reverse transcription‑quantitative polymerase chain reaction. MTT assay and flow cytometry were performed to evaluate cell viability and apoptosis, respectively. A mouse xenograft tumor model was established to observe the effects of miR‑9 on thyroid gland tumorigenesis in vivo. The present study revealed that the expression of miR‑9 was significantly reduced in PTC tissues compared with paired normal tissues. In addition, miR‑9 upregulation suppressed the expression of BRAF in TPC‑1 cells in vitro. Luciferase reporter assay demonstrated that BRAF may be a direct target gene of miR‑9 in TPC‑1 cells. In addition, following transfection with miR‑9 mimics, the viability of TPC‑1 cells was suppressed and their apoptosis was enhanced; conversely, transfection with miR‑9 inhibitor exerted the opposite effects in vitro. miR‑9 overexpression or downregulation also affected in vivo PTC tumorigenesis in athymic mice. The present findings suggested that miR‑9 may suppress the viability of PTC cells and inhibit tumor growth through directly targeting the expression of BRAF in PTC.

Does hyperthyroidism worsen prognosis of thyroid carcinoma? A retrospective analysis on 2820 consecutive thyroidectomies

Background

Hyperthyroidism is associated with high incidence of thyroid carcinoma; furthermore, tumors arisen in hyperthyroid tissue show an aggressive behavior. Thyroid Stimulating Hormone (TSH) and Thyroid-stimulating antibodies, present in Graves’s disease, seem to play a key role in carcinogenesis and tumoral growth.

Methods

We retrospectively reviewed our series of patients who underwent thyroidectomy for thyroid carcinoma. We compared pathological features and surgical outcomes of hyperthyroid versus euthyroid patients.

Results

From 2007 to 2015, 909 thyroidectomies were performed at our institution for thyroid cancer: 87 patients were hyperthyroid and 822 euthyroid. We observed, in hyperthyroid patients, a higher rate of transient hypoparathyroidism (28.1% vs 13.2%; p < 0.01) and of node metastases (12.6% vs 6.1%; p = 0.03); also local recurrence rate was higher (5.7% vs 2.5%) even if not statistically significant (p = 0.17). Five-year disease free survival rate was significant lower in the same group (89.1% vs 96.6%; p = 0.03).

Conclusion

Thyroid cancers in hyperthyroid patients have an aggressive behavior, with high incidence of local invasion and a worse prognosis than euthyroid patients. All hyperthyroid patients should undergo a careful evaluation with ultrasound and scintigraphy; in case of suspicious nodules, an aggressive approach, including thyroidectomy and lymphectomy, is justified. In patients with toxic adenoma, thyroid cancer is uncommon, thus a loboisthmectomy can be safely performed.

Trial registration number

Research registry n. 2670 registered 19 June 2017 (retrospectively registered).

Rationality in prophylactic central neck dissection in clinically node-negative (cN0) papillary thyroid carcinoma: Is there anything more to say? A decade experience in a single-center

AIM

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy. Despite its extremely favorable prognosis, cervical lymph node metastases are a common feature of PTC and a known independent risk factor for local recurrence. However, the role of prophylactic central neck dissection (PCND) remains a matter of debate in patients with clinically node-negative (cN0) PTC. To better clarify the current role of PCND in the surgical treatment of PTC, evaluating advantages and disadvantages of PCND and outcome of cN0 PTC patients who have been treated with either total thyroidectomy alone or in combination with PCND. A review of recent literature data is performed.

METHODS

Between January 2000 and December 2015, 186 consecutive patients with cN0 PTC were identified to be included in the present study. 74 of these underwent total thyroidectomy associated with PCND, while 112 patients underwent total thyroidectomy alone. The epidemiological and clinical-pathological data of all patients included were collected at diagnosis and during follow-up.

RESULTS

Overall complication rate was significantly higher in the group of patients undergoing PCND (39.2% vs. 17.8%, p = 0.0006). To be specific, they presented a considerably increased risk of temporary recurrent laryngeal nerve injury (p = 0.009) and of permanent hypothyroidism (p = 0.016). Overall survival and recurrence rates did not differ between those undergoing PCND and those undergoing total thyroidectomy alone (p = 1.000 and p = 0.715, respectively).

CONCLUSIONS

The results of the present study do not support the routine use of PCND in the treatment of cN0 PTC patients.

The New TNM Staging System for Thyroid Cancer and the Risk of Disease Downstaging

In October 2016 the American Joint Committee on Cancer (AJCC) published the 8th edition of the AJCC/TNM cancer staging system and it has been introduced in clinical practice since 1st January 2018. The effect of most of the changes in the new edition was the downstaging of a significant number of patients into lower stages, reflecting their low risk of thyroid cancer-related death. One of the most relevant modification refers to the role of the microscopic extra-thyroidal tumor invasion, which is no longer considered as criterion for the classification of T3 tumors. With the present study we want to assess the impact of the changes of the new staging system and therefore we analyzed or casistic of 84 T1-T3 thyroid-cancer patients. The results of our analysis show that he downstaging of patients according to the 8th TNM edition does not necessarily reflect less aggressive disease: we actually reported 2 lymph-nodal recurrences (40%) in the five patients that were downstaged from pT3 to pT2 and the lypmh-nodal recurrence rate for stage I rises from 0% with the 7th TNM edition to 5.3% with the 8th edition.

Combination of Maximum Shear Wave Elasticity Modulus and TIRADS Improves the Diagnostic Specificity in Characterizing Thyroid Nodules: A Retrospective Study

OBJECTIVES

The present study is aimed at evaluating the diagnostic value of combining shear wave elastography (SWE) parameters and the thyroid imaging reporting and data system (TIRADS) for differentiating between benign and malignant thyroid nodules.

METHODS

Patients who underwent conventional ultrasonography (US) and SWE before surgery were enrolled in the current study. Each nodule was given a TIRADS risk score. The effectiveness of the SWE parameters was assessed by odds ratios (ORs). The SWE scoring risk stratification was proposed beyond 95% probability, and the desired values were obtained according to the log-normal distribution. The area under the receiver-operating characteristic (AUC) was used to compare the diagnostic performance between TIRADS-alone and TIRADS + SWE.

RESULTS

A total of 262 patients with 298 thyroid nodules were enrolled in our study. The pathological analyses were conducted on 121 benign and 177 malignant nodules. The AUC values for TIRADS-alone and TIRADS + SWE were 0.896 (accuracy 83.2%) and 0.917 (accuracy 84.2%), respectively. However, the TIRADS + SWE scores showed a higher specificity (88.4%) and positive predictive value (91.2%) as compared with the TIRADS-alone of 73.6% and 83.2%, respectively.

CONCLUSIONS

Combining SWE and TIRADS improves the specificity of TIRADS-alone in differentiating between benign and malignant thyroid nodules.

Cost-effectiveness analysis in papillary thyroid carcinoma patients with different neck dissection strategy: A retrospective cohort study

BACKGROUND

There are two surgical strategies for bilateral neck dissection (BND), simultaneous and two-stage operations. The aim of the study was to compare the cost-effectiveness BND with this two operations in papillary thyroid carcinoma (PTC) patients.

MATERIALS AND METHODS

Consecutive PTC patients undergoing BND were studied retrospectively, and were classified into simultaneous group (Group A) and two-stage group (Group B). Demographic, medical costs, complication and surgical variables were recorded.

RESULTS

This study included 256 PTC patients, of which 175 (68.4%) underwent simultaneous BND and 81 (31.6%) patients underwent two-stage. Patients in Group B spent almost twice as much on medical costs as patients in Group A ($4145.3 vs. $7352.5). Group A patients also had shorter hospital stays (11.71 ± 5.12 vs. 23.10 ± 7.11, P < .0001) and surgery times (203.61 ± 61.43min vs. 279.58 ± 71.59min, P < .0001). The average radioactive iodine therapy delay was 67 days in Group B. There was no significant difference in complications (34 vs. 18, P = .605) or disease-free-survival (93.71% vs. 90.12%, P = .243) between the two groups. No difference was found in rates of recurrent laryngeal nerve invasion/resection (12 vs. 11, P = .08; 10 vs. 6, P = .353) or tracheotomy (32 vs. 14, P = .846). However, internal jugular vein invasions were more common in patients with two-stage BND (7 vs. 9, P = .029).

CONCLUSION

Simultaneous BND is the most cost-effective strategy for the management of PTC patients without bilateral internal jugular veins invasion, due to lower treatment cost and the ability to avoid RAI delay.

Evaluating the effectiveness of prophylactic central neck dissection with total thyroidectomy for cN0 papillary thyroid carcinoma: An updated meta-analysis

BACKGROUND

The effectiveness of prophylactic central neck dissection (pCND) following total thyroidectomy (TT) in patients with clinical node-negative (cN0) papillary thyroid carcinoma (PTC) is still controversial. The aim of this meta-analysis is to evaluate the outcome of pCND and to provide quantitative evidence.

METHOD

A detailed literature search of PubMed, EMBASE, ClinicalTrails.gov and Cochrane Library electronic databases for articles published up to October 2016 was carried out. This meta-analysis was performed by the random method (Mantel-Haenszel) model. Locoregional recurrence (LRR) and surgical complications were analyzed.

RESULTS

Twenty-two studies comparing pCND + TT (combined) and TT alone in cN0 PTC patients were analyzed. A total of 6930 cases were enrolled, including 2381 cases in the combined group and 4009 cases in the TT-alone group. Compared with TT alone, patients in the combined group showed a significantly lower rate of overall LRR (OR = 0.66, 95% CI = 0.48-0.89) and central compartment recurrence (OR = 0.40, 95% CI = 0.22-0.73). There was no statistical difference in the rate of lateral compartment recurrence. However, the combined group showed a significantly higher rate of temporary and permanent hypoparathyroidism (OR = 2.28, 95% CI = 1.92-2.27/OR = 1.84, 95% CI = 1.15-2.95) and temporary recurrent laryngeal nerve injury (LNR) (OR = 1.53, 95% CI = 1.08-2.16). There was no statistical difference in the rate of permanent LNR, hematoma, hemorrhage or wound infection.

CONCLUSIONS

This meta-analysis revealed that pCND with TT was a significantly efficient way to reduce the risk of LRR. However, pCND + TT increased the incidence rate of temporary and permanent hypoparathyroidism and temporary LNR.

Role of prophylactic central neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of regional recurrence

Prophylactic central neck dissection in clinically node-negative patients remains controversial. The aim of this multicenter retrospective study was to determine the rate of metastases in the central neck in clinically node-negative differentiated thyroid cancer patients, to examine the morbidity, and to assess the risk of regional recurrence in patients treated with total thyroidectomy with concomitant bilateral or ipsilateral central neck dissection compared with those undergoing total thyroidectomy alone. 258 consecutive clinically node-negative patients were divided into three groups according to the procedures performed: total thyroidectomy only (group A), total thyroidectomy with concomitant ipsilateral central neck dissection (group B), and total thyroidectomy combined with bilateral central neck dissection (group C). Mean operative time and postoperative stay were shorter in Group A (p < 0.01). The incidence of postoperative transient hypoparathyroidism was lower in Group A (p = 0.03), whereas no differences in the incidence of permanent hypoparathyroidism and nerve palsy were present. Postoperative radioactive iodine administration was higher in group B and particularly C (p = 0.03) compared with group A. There were no statistically significant differences in terms of regional recurrence. Differentiated thyroid cancer has a high rate of central lymph node metastasis even in clinically node-negative patients; in the present study there was no statistically significant difference in the rates of locoregional recurrence between the three modalities of treatment. Total thyroidectomy appears to be an adequate treatment for clinically node-negative differentiated thyroid cancer. Prophylactic central neck dissection might be considered for differentiated thyroid cancer patients with large tumor size or extrathyroidal extension.