Fatal Tracheoesophageal Puncture Leakage Associated With Lenvatinib

Tracheoesophageal puncture (TEP) is a voice restorative option adopted by many head and neck cancer patients following laryngectomy. Though generally safe, TEP may develop leakage. Lenvatinib is a tyrosine kinase inhibitor (TKI) with anti-tumoral activity against head and neck malignancies.TKIs, including lenvatinib, have been associated with organ perforation or fistula formation. There remains a paucity of literature on the association between lenvatinib and TEP leakage. In this report, we described a patient with adenoid cystic carcinoma of the larynx who had a TEP. After approximately two weeks of treatment with lenvatinib, the patient developed a leakage of TEP. Despite several interventions, the patient died three months afterward due to a retropharyngeal abscess secondary to Fusobacterium nucleatum. To our knowledge, this is the first report of fatal lenvatinib-associated TEP leakage. Clinicians should be cognizant of a potentially rapid development of this complication when prescribing TKI for patients with TEP.

Intraoperative Neuromonitoring for Thyroid Surgery in Children and Adolescents: A Single Center Experience

Intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) has been shown in adults to minimize nerve palsy after thyroid surgery, but only few studies on its efficacy in a pediatric population have been reported. We conducted a retrospective study on patients operated for thyroid lesions from 2016 to 2022. The analyzed population was divided in two groups: patients treated from 2016 to 2020, when the identification of the RLN was performed without IONM (Group A); and patients treated since 2021, when IONM was implemented in every surgical procedure on the thyroid (Group B). Intraoperative Neurophysiological Monitoring was performed by using corticobulbar motor-evoked potentials and continuous electromyography. Twentyfive children underwent thyroid resection, 19 (76%) of which due to thyroid carcinoma. Each patient's recurrent nerve was identified; IONM was used in 13 patients. In Group A, one temporary nerve palsy was identified postoperatively (8.3%), while in group B one nerve dysfunction occurred (7.7%). No statistically significant difference was found between the two groups in terms of post-operative RLN palsy. No surgical complication due to the use of IONM was reported. In children and teenagers, intraoperative neuromonitoring of the recurrent laryngeal nerve is a safe and accurate method, minimizing the risk of nerve damage.

Papillary Carcinoma Within Thyroglossal Duct Cyst: A Rare Midline Coexistence

Thyroglossal duct cysts (TDCs) develop papillary carcinomas in very rare cases. Mostly, in such cases, the diagnosis is established after the excision of a clinically benign TDC. An anterior neck mass was found in a 43-year-old man with papillary carcinoma arising in a TDC. Clinical, radiological, and analytical controls are necessary for the management of papillary carcinoma in the TDC. There is no need for thyroidectomy unless there are palpable abnormalities in the gland or significant changes on an ultrasound. The outcome of the papillary carcinoma does not seem to be significantly impacted by routinely performed thyroidectomy.

Thyroid Metastasis From Caecal Adenocarcinoma

The thyroid is a rare site of colorectal metastasis, comprising 0.1% of the surgical case series. A 62-year-old woman with caecal adenocarcinoma and previously surgically resected lung and liver metastases presented incidentally with a right thyroid nodule, which had grown and become symptomatic. Imaging revealed the nodule to have extracapsular spread, and cytology demonstrated metastatic adenocarcinoma. The patient underwent a technically challenging right thyroidectomy and neck dissection, with the final histopathological review demonstrating metastatic adenocarcinoma from a colorectal primary. The patient has subsequently undergone adjuvant radiotherapy. This case highlights an uncommon source of metastasis to the thyroid, which may aid clinicians to recognise and initiate treatment. It also highlights the technical challenges of performing surgery in such cases.

Meta-analysis of TSH suppression therapy and the risk of cardiovascular events after thyroid cancer surgery

OBJECTIVE

To investigate the relationship between TSH suppression therapy and cardiovascular events in patients with thyroid cancer after surgery.

METHODS

Pub Med, Web of Science, and Embase databases were retrieved to collect studies related to the risk of cardiovascular events in patients treated with TSH suppression after thyroid cancer surgery. RevMan statistical software was used for meta-analysis.

RESULTS

A total of 14 studies were included. The mean heart rate of patients after thyroid cancer surgery was higher than that of the control group (SMD=2.59, 95% CI: -0.37,.54), and the risk of atrial fibrillation was increased compared with the control group (RR = 1.52, 95%CI, 1.28-1.81; I = 63%). Ejection fraction and left ventricular end-diastolic diameter were not significantly different between the two groups, ejection fraction SMD = -0.10, 95% CI: -3.73, 3.52, left ventricular end-diastolic diameter SMD = -0.09, 95% CI: - 1.29, 1.11. Patients with TSH suppression after thyroid cancer had higher mean systolic blood pressure than controls (SMD = 1.97, 95% CI: -1.09, 5.03) and mean diastolic blood pressure (SMD = 1.85, 95% CI: -0.15, 3.85).

CONCLUSION

Meta-analysis concluded that TSH suppression therapy after thyroid cancer surgery increases the risk of atrial fibrillation in patients. In addition, the heart rate, systolic blood pressure and diastolic blood pressure are higher than those in the control group, and there is no significant difference in ejection fraction and left ventricular end-diastolic diameter.

Continuous intraoperative neuromonitoring for thyroid cancer surgery: A prospective study

Objective

We evaluated the utility of continuous intraoperative neuromonitoring (CIONM) during surgery for thyroid cancer (TC) in an educational university hospital.

Study Design

Prospective observational study.

Methods

During the period April 2016 to March 2017, 43 patients who underwent standardized surgery with CIONM were prospectively included: 5 men and 38 women, 24–87 years old (median 52 years); 23 lobectomies and 20 total thyroidectomies with node dissection were conducted. Thirty‐six operations were performed by a supervising surgeon, and seven were performed by trainees.

Results

Temporal vocal cord paresis (VCP) was identified in 9 of 63 nerves at risk (14.3%) by postoperative laryngoscopy. VCP was not related to clinical factors including the surgeon's experience or the severe nerve stress demonstrated by CIONM. A significant relation only between VCP and loss of signal (LOS) was demonstrated (P = .002). The recovery of VCP was rapid (<1 month) in patients with global injury even when LOS was demonstrated, but was prolonged in patients demonstrating obvious segmental nerve injury and LOS.

Conclusion

The present standard protocol of CIONM was useful to some extent to protect prolonged VCP, but not enough to detect every nerve stress causing VCP during TC surgery. On the other hand, CIONM is a promising method that could contribute surgical education at training hospitals enabling the instant confirmation of the procedure safely.

Levels of Evidence

3b

[Postoperative acute laryngeal spasm in 1 cases of thyroid cancer]

Thirty-eight years old male patient. Accepted the radical thyroidectomy for thyroid cancer in our department. When surgery was ended, laryngeal spasm occurred during pulling out the tracheal intubation, the quick check of calcium was 1.87 mmol/L, after intravenous injection the calcium gluconate the laryngeal spasm was relieved. After surgery, we gave calcium gluconate intravenously and oral Caltrate D, the patient did not appear the presence of numbness, convulsions and other symptoms. The fasting serum calcium was 2.28 mmol/L and the parathyroid hormone was 18 pg/ml before the patient discharge. In this case, we should be alert to the occurrence of low calcium and laryngeal spasm.

Protection of parathyroid function using carbon nanoparticles during thyroid surgery

OBJECTIVE

To investigate the hypothesis that injected carbon nanoparticle (CN) suspension helps identify parathyroid glands (PGs) during thyroid cancer surgery, thereby reducing PG injury.

STUDY DESIGN

A prospective, randomized controlled trial. Setting Sun Yet-san Memorial Hospital, Guangzhou, China.

SUBJECTS AND METHODS

Thyroid cancer surgeries were performed on 72 consenting patients who were randomized for conventional surgery (control group) or surgery with CN suspension injection (CN group). The primary end point was the prevalence of symptomatic hypocalcemia and serum calcium levels <1.9 mmol/L.

RESULTS

From 36 patients diagnosed with thyroid cancer in each group, symptomatic hypocalcemia was found in 10 patients without CN injection and 3 patients with CN suspension injection (P = .032). In total, 5.6% of patients in the CN group presented with muscle cramps compared with 22.2% of the control group (P = .041), which showed a significant difference.

CONCLUSION

Our randomized study revealed that CN suspension injection was feasible and appeared to be beneficial for patients undergoing thyroid surgery because the incidence of symptomatic hypocalcemia was lower compared with controls. Therefore, this technology and technique should be more widely considered for thyroid cancer therapy. Additional studies with more patients and longer follow-up times will be needed for a thorough evaluation of this methodology.