Patients Treated at Low-Volume Centers have Higher Rates of Incomplete Resection and Compromised Outcomes: Analysis of 31,129 Patients with Papillary Thyroid Cancer

Differentiated thyroid carcinoma: what the nonspecialists needs to know

Differentiated thyroid carcinoma (DTC) accounts for most cases of thyroid cancer, and the heterogeneity of DTC requires that management decisions be taken by a multidisciplinary team involving endocrinologists, head and neck surgeons, nuclear medicine physicians, pathologists, radiologists, radiation oncologists, and medical oncologists. It is important for nonspecialists to recognize and refer patients with DTC who will benefit from a specialized approach. Recent advances in knowledge and changes in management of DTC call for the need to raise awareness on the part of these nonspecialist physicians, including general endocrinologists and medical oncologists at large. We provide an overview of diagnostic and therapeutic principles in DTC, especially those that bear direct implication on day-to-day management of these patients by generalists. Patients with DTC may be broadly categorized as having localized, locally persistent/recurrent, or metastatic disease. Current recommendations for DTC include a three-tiered system that classifies patients with localized disease into low, intermediate, or high risk of persistent or recurrent disease. Risk stratification should be performed at baseline and repeated on an ongoing basis, depending on clinical evolution. One of the overarching goals in the management of DTC is the need to personalize treatment by tailoring its modality and intensity according to ongoing prognostic stratification, evolving knowledge about the disease, and patient characteristics and preference. In metastatic disease that is refractory to radioactive iodine, thyroid tumors are being reclassified into molecular subtypes that better reflect their biological properties and for which molecular alterations can be targeted with specific agents.

Five-year Outcome Between Radiofrequency Ablation vs Surgery for Unilateral Multifocal Papillary Thyroid Microcarcinoma

CONTEXT

Ultrasound (US)-guided radiofrequency ablation (RFA) has been considered as an alternative to surgery or active surveillance for papillary thyroid microcarcinoma (PTMC). However, little is known about the long-term outcomes of RFA in comparison with surgery for unilateral multifocal PTMC.

OBJECTIVE

This work aims to report the comparison between RFA vs surgery for unilateral multifocal PTMC over a more than 5-year follow-up period.

METHODS

This was a retrospective study at a primary care center with a median follow-up period of 72.9 months. A total of 97 patients with unilateral multifocal PTMC were treated with RFA (RFA group, n = 44) or surgery (surgery group, n = 53). In the RFA group, patients were treated by a bipolar RFA generator and an 18-gauge bipolar RF electrode with a 0.9-cm active tip. In the surgery group, patients underwent thyroid lobectomy with prophylactic central neck dissection.

RESULTS

During the follow-up, no statistically significant differences were found in disease progression (4.5% vs 3.8%; P = ≥.999), lymph node metastasis (2.3% vs 3.8%; P = ≥.999), persistent lesion (2.3% vs 0%; P = .272), and RFS rates (97.7% vs 96.2%; P = .673) in the RFA and surgery groups. Patients undergoing RFA had a shorter hospitalization (0 vs 8.0 [3.0] d; P < .001), shorter procedure time (3.5 [2.4] vs 80.0 [35.0] min; P < .001), lower estimated blood loss (0 vs 20.0 [15.0] mL; P < .001), and lower costs ($1768.3 [0.1] vs $2084.4 [1173.8]; P = .001) than those in the surgery group. The complication rate in the surgery group was 7.5%, whereas none of the RFA-treated patients experienced any complications (P = .111).

CONCLUSION

This study revealed 6-year comparable outcomes between RFA and surgery for unilateral multifocal PTMC. RFA may be a safe and effective alternative to surgery in selected patients with unilateral multifocal PTMC.

Disparities in Initial Thyroid Cancer Care by Hospital Treatment Volume: Analysis of 52,599 Cases in California

Background: Racially minoritized patients with thyroid cancer are less likely to receive high-quality and guideline-concordant care. Inaccessibility of high-volume centers may contribute to inequalities in thyroid cancer outcomes. This study sought to understand the extent to which access to higher volume thyroid cancer centers is associated with patient outcomes. Methods: We queried linked California Cancer Registry and California Office of Statewide Health Planning and Development databases for thyroid cancer patients who received thyroid surgery between 1999 and 2017. Hospitals were stratified by their median annual volume of thyroid cancer operations: ultra-low volume (0-5 cases/year), low-volume (6-25 cases/year), mid-volume (26-50 cases/year), and high-volume (>50 cases/year). We analyzed the rates of complications, rates of reoperation for cancer recurrence, use of radioactive iodine (131I), and mortality by median hospital volume of thyroid surgery. A multivariable regression controlled for high-risk tumor features. Differences in access by center volume were assessed based on patient demographics. Results: We studied 52,599 thyroid cancer patients who underwent thyroidectomy. Patients who underwent thyroidectomy at ultra-low volume centers were more likely to undergo reoperations for recurrent/persistent disease compared with patients at low- (odds ratio [OR] 1.17 [CI 1.02-1.35]), mid- (OR 1.25 [CI 1.06-1.46]), and high-volume centers (OR 1.26 [CI 1.03-1.56]). Patients who received thyroid operations at ultra-low volume centers were also less likely to receive guideline-concordant 131I ablation compared with patients at higher volume centers (OR 0.77 [CI 0.72-0.82]). A pair-wise comparison between all volume categories for all outcomes revealed no statistically significant differences in outcomes between low-, mid-, or high-volume centers. Only ultra-low volume centers had significantly higher rates of adverse outcomes. Ultra-low volume centers were disproportionately accessed by women (p < 0.05), Hispanic, Asian/Pacific Islander, and American Indian people (p < 0.01), those from the lowest three quintiles of socio-economic status (p < 0.01), and the uninsured and those on Medicaid or Medicare (p < 0.01) when compared with higher volume centers. Conclusions: Patients receiving thyroid cancer surgery at centers performing ≤5 such operations per year were more likely to require reoperation for recurrent/persistent disease and less likely to receive appropriate 131I ablation. Ultra-low volume centers served higher proportions of socially and economically marginalized communities.

Disparities in Presentation, Treatment, and Survival in Anaplastic Thyroid Cancer

BACKGROUND

Disparities have been previously described in the presentation, management, and outcomes of other thyroid cancer subtypes; however, it is unclear whether such disparities exist in anaplastic thyroid cancer (ATC).

METHODS

We identified patients with ATC from the National Cancer Database (2004-2020). The primary outcomes were receipt of surgery, chemotherapy, and radiation. The secondary outcome was 1-year survival. Multivariable logistic and Cox proportional hazards regressions were used to assess the associations between sex, race/ethnicity, and the outcomes.

RESULTS

Among 5359 patients included, 58% were female, and 80% were non-Hispanic white. Median tumor size was larger in males than females (6.5 vs. 6.0 cm; p < 0.001) and in patients with minority race/ethnicity than in white patients (6.5 vs. 6.0 cm; p < 0.001). After controlling for tumor size and metastatic disease, female patients were more likely to undergo surgical resection (odds ratio [OR]: 1.20; p = 0.016) but less likely to undergo chemotherapy (OR: 0.72; p < 0.001) and radiation (OR: 0.76; p < 0.001) compared with males. Additionally, patients from minority racial/ethnic backgrounds were less likely to undergo chemotherapy (OR: 0.69; p < 0.001) and radiation (OR: 0.71; p < 0.001) than white patients. Overall, unadjusted, 1-year survival was 23%, with differences in treatment receipt accounting for small but significant differences in survival between groups.

CONCLUSIONS

There are disparities in the presentation and treatment of ATC by sex and race/ethnicity that likely reflect differences in access to care as well as patient and provider preferences. While survival is similarly poor across groups, the changing landscape of treatments for ATC warrants efforts to address the potential for exacerbation of disparities.

Long-term Outcomes of Ultrasound-guided Thermal Ablation for the Treatment of Solitary Low-risk Papillary Thyroid Microcarcinoma: A Multicenter Retrospective Study

OBJECTIVE

To report more than 5-year outcomes of ultrasound-guided thermal ablation (TA) for patients with solitary low-risk papillary thyroid microcarcinoma (PTMC) in a large multicenter cohort.

BACKGROUND

TA, including radiofrequency ablation (RFA) and microwave ablation (MWA) have been used in patients with low-risk PTMC who refuse surgery or active surveillance. However, its clinical value remains controversial.

MATERIALS AND METHODS

This retrospective multicenter study included 474 patients with solitary low-risk PTMC treated with TA (357 for RFA; 117 for MWA) from 4 centers and followed up for at least 5 years. Disease progression including lymph node metastasis and recurrent tumors, volume reduction rate (VRR), tumor disappearance rate, complications, and delayed surgery were assessed. RFA and MWA outcomes were compared using propensity score matching.

RESULTS

During the median follow-up period of 77.2 months, disease progression incidence, lymph node metastasis, and recurrent tumors rates were 3.6%, 1.1%, and 2.5%, respectively. Age below 40 years old, male sex, Hashimoto thyroiditis, and tumor size were not independent factors associated with disease progression by Cox analysis. The median VRR was 100% and 471 tumors disappeared radiographically. Eight patients experienced transient voice change (1.7%) which recovered within 3 months. None of the patients underwent delayed surgery because of anxiety. After 1:1 matching, no significant differences were found in the disease progression, VRR, tumor disappearance rate, or complications between RFA and MWA subgroups.

CONCLUSION

This multicenter study revealed that TA was an effective and safe treatment for patients with solitary low-risk PTMC, which could be offered as a treatment option for the management for low-risk PTMC.

Simulated data-driven hospital selection for surgical treatment of well-differentiated thyroid cancer in older adults

BACKGROUND

Thyroid surgery at high-quality hospitals is associated with fewer complications. We evaluated the impact of referring older adults with thyroid cancer to higher-performing local hospitals.

METHODS

We performed a simulation study of Surveillance, Epidemiology, and End Results-Medicare patients, aged ≥66 years, who underwent a thyroidectomy for well-differentiated thyroid cancer (2013-2017). An 80% sample was used to calculate each hospital's risk-standardized 30-day serious adverse event rate, dividing hospitals into quartiles by performance. Hospitals located ≤30 miles of the remaining 20% of patients were compared, and 30-day serious adverse event rates and costs were simulated as if patients were treated at higher-quality hospitals using logistic regression with each alternative hospital's fixed-effect.

RESULTS

We identified 8,946 patients who underwent thyroid resection at 843 hospitals. Average risk-adjusted serious adverse event rates ranged from 13.9% to 52.9% between quartile 1 and 4 hospitals (P < .001). We identified higher-quality hospitals for 43.7% of patients. Simulating care at the best local hospital reduced predicted serious adverse event rates from 25.6% (95% confidence interval, 24.7-26.4) to 16.2% (95% confidence interval, 15.5-16.8; P < .001), while modestly lowering average costs from $12,883 (95% confidence interval, 12,500-13,267) to $12,679 (95% confidence interval, 12,304-13,056; P = .029).

CONCLUSION

Simulated care at higher-performing hospitals decreased serious adverse event rates after thyroid resection. Optimizing hospital selection may reduce postoperative morbidity without compromising preferences for local treatment.

Surgeon Thyroidectomy Case Volume Impacts Disease-free Survival in the Management of Thyroid Cancer

OBJECTIVES

To assess the association between surgeons thyroidectomy case volume and disease-free survival (DFS) for patients with well-differentiated thyroid cancer (WDTC). A secondary objective was to assess a surgeon volume cutoff to optimize outcomes in those with WDTC. We hypothesized that surgeon volume will be an important predictor of DFS in patients with WDTC after adjusting for hospital volume and sociodemographic and clinical factors.

METHODS

In this retrospective population-based cohort study, we identified WDTC patients in Ontario, Canada, who underwent thyroidectomy confirmed by both hospital-level and surgeon-level administrative data between 1993 and 2017 (N = 37,233). Surgeon and hospital volumes were calculated based on number of cases performed in the year prior by the physician and at an institution performing each case, respectively and divided into quartiles. A multilevel hierarchical Cox regression model was used to estimate the effect of volume on DFS.

RESULTS

A crude model without patient or treatment characteristics demonstrated that both higher surgeon volume quartiles (p < 0.001) and higher hospital volume quartiles (p < 0.001) were associated with DFS. After controlling for clustering and patient/treatment covariates and hospital volume, moderately low (18-39/year) and low (0-17/year) volume surgeons (hazard ratios [HR]: 1.23, 95% confidence interval [CI]: 1.09-1.39 and HR: 1.34, 95% CI: 1.17-1.53 respectively) remained an independent statistically significant negative predictor of DFS.

CONCLUSION

Both high-volume surgeons and hospitals are predictors of better DFS in patients with WDTC. DFS is higher among surgeons performing more than 40 thyroidectomies a year.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Surgical Case Volume has an Impact on Outcomes for Patients with Lateral Neck Disease in Thyroid Cancer

BACKGROUND

This study aimed to assess whether surgical case volume for lateral neck dissection has an impact on the survival of patients who have well-differentiated thyroid cancer (WDTC) with lateral cervical node metastases. The authors used a population-based cohort study design.

METHODS

The study cohort consisted of WDTC patients in Ontario Canada who underwent thyroidectomy and lateral neck dissection. These patients were identified using both hospital- and surgeon-level administrative data between 1993 and 2017 (n = 1832). Surgeon and hospital volumes were calculated based on the number of cases managed in the year before the procedure by the physician and at the institution managing each case, respectively, and divided into tertiles. Multilevel Cox regression models were used to estimate the effect of volume on disease-free survival (DFS).

RESULTS

A crude model without patient or treatment characteristics demonstrated that DFS was associated with both higher surgeon volume tertiles (p < 0.01) and higher hospital volume tertiles (p < 0.01). After control for clustering, patient/treatment covariates, and hospital volume, the lowest surgeon volume tertile (range, 0-20/year; mean, 6.5/year) remained an independent statistically significant negative predictor of DFS (hazard ratio, 1.71; 95 % confidence interval, 1.22-2.4; p < 0.01).

CONCLUSION

Surgeon lateral neck dissection case volume is a predictor of better DFS for thyroid cancer patients, with the lowest surgeon volume tertile (<20 neck dissections per year) demonstrating poorer DFS.

Association of the Affordable Care Act with access to highest-volume centers for patients with thyroid cancer

BACKGROUND

Disparities exist in access to high-volume surgeons, who have better outcomes after thyroidectomy. The association of the Affordable Care Act's Medicaid expansion with access to high-volume thyroid cancer surgery centers remains unclear.

METHODS

The National Cancer Database was queried for all adult thyroid cancer patients diagnosed from 2010 to 2016. Hospital quartiles (Q1-4) defined by operative volume were generated. Clinicodemographics and adjusted odds ratios for treatment per quartile were analyzed by insurance status. An adjusted difference-in-differences analysis examined the association between implementation of the Affordable Care Act and changes in payer mix by hospital quartile.

RESULTS

In total, 241,448 patients were included. Medicaid patients were most commonly treated at Q3-Q4 hospitals (Q3 odds ratios 1.05, P = .020, Q4 1.11, P < .001), whereas uninsured patients were most often treated at Q2-Q4 hospitals (Q2 odds ratios 2.82, Q3 2.34, Q4 2.07, P < .001). After expansion, Medicaid patients had lower odds of surgery at Q3-Q4 compared with Q1 hospitals (odds ratios Q3 0.82, P < .001 Q4 0.85, P = .002) in expansion states, but higher odds of treatment at Q3-Q4 hospitals in nonexpansion states (odds ratios Q3 2.23, Q4 1.86, P < .001). Affordable Care Act implementation was associated with increased proportions of Medicaid patients within each quartile in expansion compared with nonexpansion states (Q1 adjusted difference-in-differences 5.36%, Q2 5.29%, Q3 3.68%, Q4 3.26%, P < .001), and a decrease in uninsured patients treated at Q4 hospitals (adjusted difference-in-differences -1.06%, P = .001).

CONCLUSIONS

Medicaid expansion was associated with an increased proportion of Medicaid patients undergoing thyroidectomy for thyroid cancer in all quartiles, with increased Medicaid access to high-volume centers in expansion compared with nonexpansion states.

Margin Positivity and Survival in Papillary Thyroid Microcarcinoma: A National Cancer Database Analysis

BACKGROUND

The rising incidence of thyroid cancer has been attributed to increased detection of papillary thyroid microcarcinoma (PTMC). Although some PTMCs are thought to harbor aggressive pathologic features, the clinical significance of these features remains unclear. This study examines factors associated with survival in this patient population.

STUDY DESIGN

Adults with PTMC, defined as papillary thyroid carcinoma ≤ 1.0 cm, who underwent thyroidectomy between 2004 and 2016, were identified in the National Cancer Database. Demographic and clinical variables were analyzed. The primary aim was to identify factors associated with survival. The secondary aim was to assess the association of microscopic margins on survival and to identify factors associated with margin positivity. Overall survival was estimated using Kaplan-Meier methods and compared using log rank tests. Cox proportional hazards and binary logistic regression models identified factors associated with survival and margin positivity, respectively.

RESULTS

Of 77,817 patients with PTMC, 13,507 met inclusion criteria; 2,649 (20%) of these patients presented with advanced features: extrathyroidal extension (n = 916, 7%), lymphovascular invasion (n = 398, 3%), lymph node involvement (n = 2,003, 15%), and distant metastasis (n = 39, <1%). Microscopic margin positivity was present in 906 patients and associated with increased risk of death (hazard ratio 1.58, 95% CI 1.04-2.41). Academic facilities (odds ratio [OR] 0.75, 95% CI 0.59-0.95) and operative volume (OR 0.98, 95% CI 0.97-0.98) were associated with decreased margin positivity.

CONCLUSIONS

Positive margin status was significantly associated with increased risk of death for PTMC. Higher operative volume and treatment at academic centers were associated with lower rates of margin positivity and may help improve survival outcomes in PTMC patients with aggressive features.

Outcomes of Tracheal Resections in Well-Differentiated Thyroid Cancer-A case series and meta-analysis

BACKGROUND

Tracheal invasion in thyroid cancer is a well-known form of advanced disease. There is an ongoing controversy over outcomes of tracheal shaving in this situation. The aim of this study was to compare the results of tracheal shaving to radical resections in patients with low-volume tracheal involvement.

METHODS

An institutional case series and a meta-analysis was conducted. All studies that included patients diagnosed with well-differentiated thyroid cancer (WDTC) and tracheal invasion were analyzed. Patients with low-volume tracheal invasion (according to the Shin classification) were extracted from the various studies and subsequently included in this study. The outcomes of tracheal shaving and radical resection were consolidated and compared. All recurrences and mortality over 10 years of follow-up were calculated using the Kaplan-Meier method.

RESULTS

Institutional case series included 22 patients diagnosed with WDTC and tracheal invasion that underwent resection. There was one case of recurrence (4.5%) during the follow-up period and no mortality. The meta-analysis yielded a total of 284 patients from six studies who met the inclusion criteria. The 10-year overall survival was 82.4% for the shave group and 80.8% for the resection group. The combined Kaplan-Meier curves revealed no statistically significant difference between the two techniques (hazard ratio [HR] = 0.86, P = .768). The combined 10-year local control rate of the shave group was 90.2%.

CONCLUSIONS

The outcomes of tracheal shaving in low-volume invasion are similar to more aggressive forms of tracheal resections. Shave resection is oncologically safe in carefully selected WDTC patients demonstrating minimal tracheal invasion.

Five-year follow-up results of thermal ablation for low-risk papillary thyroid microcarcinomas: systematic review and meta-analysis

OBJECTIVES

Confidence in long-term treatment results of thermal ablation for papillary thyroid microcarcinoma (PTMC) is required in comparison with active surveillance. The objective of this meta-analysis is to report 5-year follow-up results of thermal ablation for PTMC.

METHODS

Ovid MEDLINE and EMBASE databases were searched through May 30, 2020, for studies reporting outcomes in patients with PTMC treated with thermal ablation and followed up for at least 5 years. Data were extracted and methodological quality was assessed independently by two radiologists according to the PRISMA guidelines.

RESULTS

Three studies, involving 207 patients with 219 PTMCs, met the inclusion criteria through database searches. None of these patients experienced local tumor recurrence, lymph node metastasis, or distant metastasis or underwent delayed surgery during a mean pooled 67.8-month follow-up. Five new tumors appeared in the remaining thyroid gland of four patients, with four of these tumors successfully treated by repeat thermal ablation. The pooled mean major complication rate was 1.2%, with no patient experiencing life-threatening or delayed complications.

CONCLUSIONS

Thermal ablation is an excellent local tumor control method in patients with low-risk PTMC, with low major complication rates at 5 years.

KEY POINTS

• No local tumor recurrence, lymph node metastasis, or distant metastasis was noted by thermal ablation during follow-up of 5 years and none underwent delayed surgery. • The pooled mean major complication rate was 1.2%.

Thyroid Nodule Evaluation and Management in Older Adults: A Review of Practical Considerations for Clinical Endocrinologists

OBJECTIVE

Contextualizing the evaluation of older adults with thyroid nodules is necessary to fully understand which management strategy is the most appropriate. Our goal was to summarize available clinical evidence to provide guidance in the care of older adults with thyroid nodules and highlight special considerations for thyroid nodule evaluation and management in this population.

METHODS

We conducted a literature search of PubMed and Ovid MEDLINE from January 2000 to November 2020 to identify relevant peer-reviewed articles published in English. References from the included articles as well as articles identified by the authors were also reviewed.

RESULTS

The prevalence of thyroid nodules increases with age. Although thyroid nodules in older adults have a lower risk of malignancy, identified cancers are more likely to be of high-risk histology. The goals of thyroid nodule evaluation and the tools used for diagnosis are similar for older and younger patients with thyroid nodules. However, limited evidence exists regarding thyroid nodule evaluation and management to guide personalized decision making in the geriatric population.

CONCLUSION

Considering patient context is significant in the diagnosis and management of thyroid nodules in older adults. When making management decisions in this population, it is essential to carefully weigh the risks and benefits of thyroid nodule diagnosis and treatment, in view of older adults' higher prevalence of high-risk thyroid cancer as well as increased risk for multimorbidity, functional and cognitive decline, and treatment complications.

Initial treatment of patients with thyroid cancer: Outcomes and factors associated with care at academic versus nonacademic cancer centers

BACKGROUND

Factors associated with receiving initial care for thyroid cancer (TC) at academic centers (ACs) versus nonacademic centers (NACs) and their impact on patient outcomes have not been reported.

METHODS

The National Cancer Database with TC cases from 2004 to 2013 was evaluated for association of type of center for initial care with socioeconomic factors and disease and treatment characteristics, as well as overall survival (OS; all-cause mortality).

RESULTS

The patients with TC (n = 200,824) included were predominantly women (74%), non-Hispanic Whites (85%), and from metro areas (84%). Sixty percent received initial care at a NAC. There were no significant differences between treatment groups by age or gender. Among those treated at an AC, a higher proportion belonged to racial/ethnic minorities (16.5%) versus at a NAC (11.6%). Hormone therapy was used more in an AC versus a NAC (60% vs 47%). Patients with all TC pathologies combined had a lower likelihood of death when they received initial care at an AC (hazard ratio [HR], 0.948; P = .0006). Among individual pathologic subtypes, a lower likelihood of death was noted when initial care was received at an AC for follicular (HR, 0.828, P = .0010) and Hurthle cell cancers (HR, 792; P = .0008), as well as stage II papillary thyroid cancer (HR, 0.828; P = .0026), but not for other histopathologic subtypes.

CONCLUSIONS

Initial care at an AC was associated with lower likelihood of death for patients with TC, especially for those with follicular or Hurthle cell subtypes. Optimal resource use with consideration of patients' socioeconomic and demographic factors is imperative to ensure the most appropriate management of patients with TC in various treatment settings.

Web-Based Ultrasonic Nomogram Predicts Preoperative Central Lymph Node Metastasis of cN0 Papillary Thyroid Microcarcinoma

BACKGROUND

Many clinicians are facing the dilemma about whether they should apply the active surveillance (AS) strategy for managing Clinically Node-negative (cN0) PTMC patients in daily clinical practice. This research plans to construct a dynamic nomogram based on network, connected with ultrasound characteristics and clinical data, to predict the risk of central lymph node metastasis (CLNM) in cN0 PTMC patients before surgery.

METHODS

A retrospective analysis of 659 patients with cN0 PTMC who had underwent thyroid surgery and central compartment neck dissection. Patients were randomly (2:1) divided into the development cohort (439 patients) and validation cohort (220 patients). The group least absolute shrinkage and selection operator (Group Lasso) regression method was used to select the ultrasonic features for CLNM prediction in the development cohort. These features and clinical data were screened by the multivariable regression analysis, and the CLNM prediction model and web-based calculator were established. Receiver operating characteristic, calibration curve, Clinical impact curve and decision curve analysis (DCA) were used to weigh the performance of the prediction model in the validation set.

RESULTS

Multivariable regression analysis showed that age, tumor size, multifocality, the number of contact surface, and real-time elastography were risk factors that could predict CLNM. The area under the curve of the prediction model in the development and validation sets were 0.78 and 0.77, respectively, with good discrimination and calibration. A web-based dynamic calculator was built. DCA proved that the prediction model had excellent net benefits and clinical practicability.

CONCLUSIONS

The web-based dynamic nomogram incorporating US and clinical features was able to forecast the risk of preoperative CLNM in cN0 PTMC patients, and has good predictive performance. As a new observational indicator, NCS can provide additional predictive information.

The impact of surgeon volume on total thyroidectomy outcomes among otolaryngologists

PURPOSE

To evaluate the impact of surgeon volume on total thyroidectomy complications and outcomes among otolaryngologists.

MATERIALS AND METHODS

This state-wide, multi-hospital retrospective review identified patients who underwent total thyroidectomy (TT) (ICD9-06.4) through the Statewide Planning and Research Cooperative System (SPARCS) between 1995 and 2015. Surgeons were categorized into high (>100), medium (10-99), and low (<10) volume groups and differences in complication rates were analyzed. Statistical analysis employed Spearman's rank correlation, Kruskal-Wallis testing, and chi-squared testing.

RESULTS

32,133 TT performed by 1032 otolaryngologists were identified. Overall complication rate in our cohort was 9.83% (CI: 9.48-10.18). The most common complication identified overall was hypocalcemia occurring in 3.85% of cases. Surgeons in the high volume group had a complication rate of 9.6%, compared to 10.0% and 11.6% in the medium and low volume groups. This represents a moderate, but statistically significant difference (rho: -0.4, p < 0.0001; KW p ≤0.0001). When looking at individual complications, temporary tracheostomy rate was higher in the low volume group (5.1%, p = 0.001). Other variables such as advanced age, sex, non-white race, or thyroid malignancy were not predictors of increased complication rates for TT.

CONCLUSIONS

Otolaryngologists who perform a high volume of total thyroidectomy were found to have overall less perioperative complications than those with less volume. In particular, the risk of temporary tracheostomy is higher among low volume surgeons. These findings are consistent with previous studies of the effect of thyroidectomy volume on surgical complications.

Volume, outcomes, and quality standards in thyroid surgery: an evidence-based analysis-European Society of Endocrine Surgeons (ESES) positional statement

INTRODUCTION

Continuous efforts in surgical speciality aim to improve outcome. Therefore, correlation of volume and outcome, developing subspecialization, and identification of reliable parameters to identify and measure quality in surgery gain increasing attention in the surgical community as well as in public health care systems, and by health care providers. The need to investigate these correlations in the area of endocrine surgery was identified by ESES, and thyroid surgery was chosen for this analysis of the prevalent literature with regard to outcome and volume.

MATERIALS AND METHODS

A literature search that is detailed below about correlation between volume and outcome in thyroid surgery was performed and assessed from an evidence-based perspective. Following presentation and live data discussion, a revised final positional statement was presented and consented by the ESES assembly.

RESULTS

There is a lack of prospective randomized controlled studies for all items representing quality parameters of thyroid surgery using uniform definitions. Therefore, evidence levels are low and recommendation grades are based mainly on expert and peer evaluation of the prevalent data.

CONCLUSION

In thyroid surgery a volume and outcome relationship exists with respect to the prevalence of complications. Besides volume, cumulative experience is expected to improve outcomes. In accordance with global data, a case load of < 25 thyroidectomies per surgeon per year appears to identify a low-volume surgeon, while > 50 thyroidectomies per surgeon per year identify a high-volume surgeon. A center with a case load of > 100 thyroidectomies per year is considered high-volume. Thyroid cancer and autoimmune thyroid disease predict an increased risk of surgical morbidity and should be operated by high-volume surgeons. Oncological results of thyroid cancer surgery are significantly better when performed by high-volume surgeons.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

The Impact of Hospital Quality on Thyroid Cancer Survival

Objective

To develop a composite measure of thyroid cancer–specific hospital quality and to evaluate the association between hospital quality and survival in patients with well-differentiated thyroid cancer.

Study Design

Retrospective cohort study.

Setting

Population-based cancer database.

Subjects and Methods

Data were extracted from the California Cancer Registry data set linked with discharge records and hospital characteristics from the California Office of Statewide Health Planning and Development. The study cohort comprised adult patients with well-differentiated thyroid cancer diagnosed between January 1, 2004, and December 31, 2015. Principal component analysis, incorporating hospital volume, adherence to national guidelines, and accreditation/certification status, was used to generate a composite thyroid cancer–specific hospital quality score.

Results

Treatment in hospitals ranked in the highest quartile of quality was associated with improved overall survival (OS) (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.67-0.98) and disease-specific survival (DSS) (HR, 0.72; 95% CI, 0.54-0.98). Treatment in hospitals meeting the combined metric of 10 or more thyroid cancer cases/year and 80% of patients with high-risk tumors treated with total/near-total thyroidectomy was associated with improved OS (HR, 0.80; 95% CI, 0.70-0.90) and DSS (HR, 0.77; 95% CI, 0.64-0.94).

Conclusion

Treatment in high-quality hospitals is associated with improved survival outcomes in patients with thyroid cancer. These findings are important because they help identify hospitals that are better suited to treat patients with thyroid cancer and provide actionable targets for quality improvement.

Active Surveillance of Papillary Thyroid Microcarcinoma: Where Do We Stand?

The recent sharp increase in thyroid cancer incidence is mainly due to increased detection of small papillary thyroid microcarcinoma (PTMC). Due to the indolent nature of the disease, active surveillance (AS) of low-risk PTMCs is suggested as an alternative to immediate surgery to reduce morbidity from surgery. For appropriately selected PTMC patients, AS can be a good management option and surgical intervention can be safely delayed until progression occurs. Many considerations must be taken into account at the time of initiation of AS, including radiological tumor characteristics and clinical characteristics of the patient. A specialized medical team should be assembled to monitor patients during AS with an appropriate follow-up protocol. The fact that some patients require surgery for disease progression after long-term follow-up is a major drawback of the current AS protocol. Evaluation of tumor kinetics by three-dimensional tumor volume measurement during the initial 2-3 years of AS may be helpful for discrimination of PTMCs that need early surgical intervention. In this review, we will discuss the clinical outcomes of surgical intervention and AS, considerations during AS, and unresolved questions about AS.

Effect of Travel Time for Thyroid Surgery on Treatment Cost and Morbidity

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time–related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients’ home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1–107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.

Management of Low-Risk Papillary Thyroid Cancer

The incidence of thyroid cancer has increased, mainly due to the incidental finding of low-risk papillary thyroid cancers (PTC). These malignancies grow slowly, and are unlikely to cause morbidity and mortality. New understanding about the prognosis of tumor features has led to reclassification of many tumors within the low-risk thyroid category, and to the development of a new one "very low-risk tumors." Alternative less aggressive approaches to therapy are now available including active surveillance and minimally invasive interventions. In this narrative review, we have summarized the available evidence for the management of low-risk PTC.

Microscopic positive margins in papillary thyroid cancer do not impact disease recurrence

BACKGROUND

The prognostic significance of microscopic positive margins in papillary thyroid carcinoma (PTC) remains unclear. The aim of this study was to determine if microscopic positive margins are associated with increased risk of disease recurrence.

METHODS

This is a retrospective analysis of 610 patients with PTC using multivariate Cox regression to evaluate the association between microscopic positive margins and disease-free survival.

RESULTS

Microscopic positive margins were found in 67 (11%) patients and associated with extrathyroidal extension (P < 0.001), multifocality (P < 0.001), nodal metastases (P < 0.001), lymphovascular invasion (P < 0.001), age ≥55 years (P = 0.048), administration of radioactive iodine (RAI) therapy (P = 0.001) and a trend towards larger tumour size (18 versus 15 mm; P = 0.074). After a median follow-up of 3.4 years, there were 83 recurrences. Although involved margins were associated with increased risk of recurrence on univariate analysis (hazard ratio 2.6, 95% confidence interval 1.5-4.6; P = 0.001), there was no association after adjusting for age, nodal metastases, tumour size and extrathyroidal extension on multivariate analysis (hazard ratio 1.5, 95% confidence interval 0.8-2.9; P = 0.242). Similar results were obtained after adjusting for RAI and if margins were analysed as focal versus widely positive. In our study cohort, patients with involved margins generally had other indications for RAI. However, in the nine patients who did not receive RAI, there was no recurrence in the thyroid bed.

CONCLUSION

Despite a strong association between microscopic positive margins and other adverse prognostic factors in PTC, there is no independent association with disease recurrence on multivariate analysis. Microscopic positive margins are rare (1.1%) in the absence of other indications for RAI.

Active Surveillance of Papillary Thyroid Microcarcinoma: A Mini-Review from Korea

In Korea, the incidence of thyroid cancer increased explosively in the early 2000s, and reached a plateau in the early 2010s. Most cases of newly diagnosed thyroid cancer are small indolent microcarcinoma and could be good candidates for active surveillance (AS) instead of immediate surgery. Many considerations must be taken into account for establishing selection criteria for candidates for AS of papillary thyroid microcarcinoma (PTMC), including the characteristics of the tumor, the patient, and the medical team. If possible, AS of PTMC should be a part of a prospective clinical trial to ensure long-term safety and to identify clinical and/or molecular markers of the progression of PTMC. In this review, we discuss lessons regarding surgical interventions for PTMC, and then describe the concept, application, caveats, unanswered questions, and future perspectives of AS of PTMC. For appropriately selected patients with PTMC, AS can be a good alternative to immediate surgery.

Occult invasion of sternothyroid muscle by differentiated thyroid cancer

PURPOSE

To determine the incidence of occult invasion of sternothyroid by differentiated thyroid cancer (DTC) and identify clinico-pathological features associated with the same.

METHODS

Retrospective study of a consecutive series of DTC patients undergoing surgery, with preoperative ultrasound showing no evidence of strap muscle invasion. All had en bloc excision of sternothyroid muscle along with thyroidectomy. Incidence of microscopic invasion of sternothyroid and clinicopathologic features associated with the same, were studied.

RESULTS

A total of 76 patients with DTC (2010-2014) were identified, of whom 62 met the inclusion criteria and were included in this study. Of these, 22 (36%) had no extrathyroidal extension (ETE), 30 (48%) had minimal ETE without sternothyroid invasion and 10 (16%) had minimal ETE with microscopic sternothyroid invasion. The mean tumor sizes of the three sub-groups were 1.9, 3.1 and 4.9 cm, respectively, with a significant difference between no ETE and sternothyroid invaded sub-groups (p = 0.03). Out of the 40 cases with minimal ETE, 3 (7.5%) had positive tumor microscopic margin. Retaining sternothyroid in situ would have theoretically increased this proportion to 27.5%. Over a median follow-up of 52 months, 58 (94%) patients remained structurally disease free, with only 1 local recurrence.

CONCLUSION

Occult invasion of sternothyroid muscle occurred in 16% of DTC in this series. Excision of the muscle en bloc with thyroidectomy, particularly in larger tumors, may confer benefit in accurately staging the disease, encompassing occult ETE and achieving clear microscopic margins.

Population-Based Assessment of Complications Following Surgery for Thyroid Cancer

CONTEXT

As thyroid cancer incidence rises, more patients undergo thyroid surgery. Although postoperative complication rates have been reported in single institution studies, population-based data are limited.

OBJECTIVE

To determine thyroid cancer surgery complication rates and identify at-risk populations.

DESIGN/SETTING/PATIENTS

Using the Surveillance, Epidemiology, and End Results-Medicare database, we evaluated general complications within 30 days and thyroid surgery-specific complications within 1 year in 27,912 patients who underwent surgery for differentiated or medullary thyroid cancer between 1998 and 2011. Multivariable analyses of patient characteristics associated with postoperative complications were performed.

MAIN OUTCOME MEASURES

General and thyroid surgery-specific complications.

RESULTS

Overall, 1820 (6.5%) patients developed general postoperative complications and 3427 (12.3%) developed thyroid surgery-specific complications. In multivariable analyses, general and thyroid surgery-specific complications were significantly higher in patients >65 years [odds ratio (OR), 2.61; 95% confidence interval (CI), 2.31 to 2.95; OR, 3.12; 95% CI, 2.85 to 3.42], those with a Charlson/Deyo comorbidity score of 1 (OR, 2.40; 95% CI, 1.66 to 3.49; OR, 1.88; 95% CI, 1.53 to 2.31) and ≥2 (OR, 7.05; 95% CI, 5.33 to 9.56; OR, 3.62; 95% CI, 3.11 to 4.25), and those with regional (OR, 1.18; 95% CI, 1.03 to 1.35; OR, 1.31; 95% CI, 1.19 to 1.45) or distant disease (OR, 2.83; 95% CI, 2.30 to 3.47; OR, 1.85; 95% CI, 1.54 to 2.21), respectively.

CONCLUSIONS

The rates of thyroid cancer surgery complications are higher than predicted, and patients with older age, more comorbidities, and advanced disease are at greatest risk. Efforts to reduce complications are needed.

REFERRAL OF OLDER THYROID CANCER PATIENTS TO A HIGH-VOLUME SURGEON: RESULTS OF A MULTIDISCIPLINARY PHYSICIAN SURVEY

OBJECTIVE

Surgical outcomes of thyroid cancer patients are improved with high-volume surgeons. However, age disparities in referral to specialist surgical centers still exist. The factors that influence decision making regarding referral of older thyroid cancer patients to high-volume surgeons remain unknown.

METHODS

We surveyed members of the Endocrine Society, American College of Physicians, and American Academy of Family Practice.

RESULTS

Overall, 270 physicians completed the survey. Patient preference (69%), transportation barriers (62%), and confidence in local surgeon (54%) were the most cited factors decreasing likelihood of referral to a high-volume surgeon. In clinical scenarios, referral rates to a high-volume surgeon were similar for patients aged 40 and 65 years with a 1-cm thyroid nodule diagnostic of thyroid cancer (n = 137 [54%]; n = 132 [52%], respectively) as for an 85-year-old with a 4-cm nodule (n = 148 [59%]). When comorbidities were introduced, more physicians (n = 186 [74%]) would refer a 65-year-old with a 4-cm thyroid nodule and comorbidities, compared to an 85-year-old with the same nodule size without comorbidi-ties. In multivariable analysis, treating >10 thyroid cancer patients/year (P<.001; P<.005) and endocrinology specialty (P = .003; P = .003) were associated with referral to a high-volume surgeon for a 65-year-old with comorbidities and an 85-year-old without comorbidities, respectively.

CONCLUSION

Understanding surgical referral patterns of older thyroid cancer patients is vital in identifying obstacles in the referral process. We found that patient factors including comorbidities and physician factors including specialty and patient volume influence these patterns. This is the first step towards developing targeted interventions for these patients.

A Tale of Two Cancers: Traveling to Treat Pancreatic and Thyroid Cancer

BACKGROUND

Patients diagnosed with a malignancy must decide whether to travel for care at an academic center or receive treatment at a nearby hospital. Here we examine differences in demographics, treatment, and outcomes of those traveling to academic centers for their care vs those not traveling, as well as compare travel for an aggressive vs indolent malignancy.

STUDY DESIGN

All patients with papillary thyroid carcinoma (PTC) or pancreatic ductal adenocarcinoma (PDAC) undergoing surgical resection and in the National Cancer Database were examined. Travel for care was abstracted from "crowfly" distance between patients' ZIP codes and treatment facility, region, county size, urban/metro/rural status, and facility type.

RESULTS

In total, 105,677 patients with PTC and 22,983 patients with PDAC were analyzed. There were no survival differences by travel in the PTC group. Survival was improved for patients with PDAC traveling from urban/rural settings (hazard ratio = 0.89; 95% CI 0.82 to 0.96; p = 0.002). Patients traveling with PDAC were more likely to have a complete resection and lymph node dissection. Those traveling were less likely to receive chemotherapy or radiotherapy (all p < 0.001). Those traveling with PTC were older, more likely to be male, have Medicare insurance, and had a higher stage of disease (all p < 0.001). Rates of radioactive iodine were lower, American Thyroid Association guidelines were more likely followed, and lymph node dissection was more common for those traveling for care of their PTC (all p < 0.001).

CONCLUSIONS

There are improvements in both quality and survival for those traveling to academic centers for their cancer care. In the case of PTC, this difference in quality did not affect overall survival. In PDAC, however, differences in quality translated to a survival advantage.

Management of Invasive Differentiated Thyroid Cancer

BACKGROUND

Invasive disease is a poor prognostic factor for patients with differentiated thyroid cancer (DTC). Uncontrolled central neck disease is a common cause of distressing death for patients presenting in this manner. Advances in assessment and management of such cases have led to significant improvements in outcome for this patient group. This article reviews the patterns of invasion and a contemporary approach to investigation and treatment of patients with invasive DTC.

SUMMARY

Aerodigestive tract invasion is reported in around 10% of case series of DTC. Assessment should include not only clinical history and physical examination with endoscopy as indicated, but ultrasound and contrast-enhanced cross-sectional imaging. Further studies including positron emission tomography should be considered, particularly in recurrent cases that are radioactive iodine (RAI) resistant. Both the patient and the extent of disease should be carefully assessed prior to embarking on surgery. The aim of surgery is to resect all gross disease. When minimal visceral invasion is encountered early, "shave" procedures are recommended. In the setting of transmural invasion of the airway or esophagus, however, full thickness excision is required. For intermediate cases in which invasion of the viscera has penetrated the superficial layers but is not evident in the submucosa, opinion is divided. Early reports recommended an aggressive approach. More recently authors have tended to recommend less aggressive resections with postoperative adjuvant therapies. The role of external beam radiotherapy continues to evolve in DTC with support for its use in patients considered to have RAI-resistant tumors.

CONCLUSIONS

Patients with invasive DTC require a multidisciplinary approach to investigation and treatment. With detailed assessment, appropriate surgery, and adjuvant therapy when indicated, this patient group can expect durable control of central neck disease, despite the aggressive nature of their primary tumors.

Value-based healthcare: implications for thyroid cancer

Today's delivery of care to thyroid cancer patients is complex, and costly, with uneven outcomes that can be improved. The incidence of thyroid cancer is rising and requires coordinated, multidisciplinary care with high volume centers that is not always available in our current fragmented healthcare system. To address the needs of patients, providers and payers, we believe that thyroid cancer care needs to be reexamined from the perspective of value for the patient, which is defined as the outcomes that matter to patients relative to the cost of delivering them. This paper provides recommendations based on the key principles of the value-based approach to transform the delivery of thyroid cancer care.