Robot-Assisted Transaxillary Thyroid Surgery in the United States: Is it Comparable to Open Thyroid Lobectomy?

Background  

The purpose of this study was to compare the outcome of robot-assisted transaxillary thyroid surgery (RATS) to the standard open technique for thyroid lobectomy in the U.S. population.     

Medullary Thyroid Cancer: Are Practice Patterns in the United States Discordant From American Thyroid Association Guidelines?

Background  

Surgery is the mainstay of treatment for medullary thyroid cancer (MTC), with long-term patient outcomes associated with adequacy of resection. This study benchmarked national practice patterns against 2009 American Thyroid Association (ATA) guidelines for MTC regarding use of thyroidectomy, lymphadenectomy, radioactive iodine (RAI), and external-beam radiotherapy (EBRT).     

Thyroid surgery: generalist or specialist?

BACKGROUND: Thyroid surgery is done in Germany in a considerable numbers of operations (about 110,000 per year). To perform thyroid operations by so called "generalists" or "specialists" have been discussed intensively, however, this issue have not been analyzed in detail. METHODS: Study material comprised 16,500 consecutive thyroid operations with 30,000 operated sites that have been prospectively documented in the German Thyroid Multicenter Study performed 1998 through 2001. Quality of surgery were analyzed by calculating the inverse relationship between volume and outcome (complication rate). RESULTS: To achieve complication rates (permanent unilateral recurrent laryngeal nerve paralysis and hypocalcemia) of < 1 % (primary surgery) or < 3 % (redo surgery) the minimum number of thyroid operations of lower level of experience (e. g. benign nodular goiter) per year was n=30. The minimum number of operations with higher level of experience was significantly lower (n=3-12) due to the higher level of experience of operating surgeons. In contrast to the rates of postoperative hypocalcemia the rates of postoperative recurrent laryngeal nerve paralysis was clearly related to the number of thyroid operations performed. CONCLUSIONS: The high number of thyroid operations in Germany with about 20 % of operations of high level experience are requiring surgical curricula and hospital structures that offer as well generalists as specialists to treat the broad spectrum of thyroid diseases accordingly. To lower the complication rate especially of difficult thyroid operations the level of specialization in Germany have to be increased.     

Does Hürthle Cell Carcinoma of the Thyroid Have a Poorer Prognosis than Ordinary Follicular Thyroid Carcinoma?

Background

Hürthle cell carcinoma (HCC) is a rare form of thyroid carcinoma and is considered an oxyphilic variant of follicular thyroid carcinoma. However, little is known about its biological characteristics or clinical behavior. We conducted a retrospective study to determine whether the prognosis of HCC differs from that of ordinary follicular thyroid carcinoma (OFC).

Methods

The subjects were the 558 patients with follicular thyroid carcinoma who underwent initial surgery at our institution between 1989 and 2010 and consisted of 73 patients with HCC and 485 patients with OFC. There were 410 females and 148 males, and their median age was 51 years. A univariate analysis was conducted in relation to cumulative cause-specific survival (CSS) according to the Kaplan–Meier method for the following variables: age at the time of initial surgery, gender, tumor size, invasiveness, distant metastasis at presentation, and histological type (HCC vs OFC). Differences between groups were analyzed for significance by the log-rank test. Multivariate analysis was performed by using the Cox proportional hazard model.

Results

A total of 4 patients (5.5 %) in the HCC group had distant metastasis compared with 106 patients (21.9 %) in the OFC group. Significant factors in relation to CSS in the univariate analyses were age, tumor size, and invasiveness, but there were no significant differences between the HCC group and the OFC group. Multivariate analysis showed that age, tumor size, and distant metastasis at presentation were significant factors.

Conclusions

HCC does not have a poorer prognosis than OFC.     

Special Variants of Differentiated Thyroid Cancer: Does It Alter the Extent of Surgery Versus Well-Differentiated Thyroid Cancer?

Introduction Recently, more aggressive variants of so-called well-differentiated thyroid carcinomas have been identified such as the tall cell variant, columnar cell variant, diffuse sclerosing variant, insular carcinoma, and Hürthle cell (oncocytic, oxyphilic) carcinomas. Methods An evidence-based review was performed to identify the optimal treatment recommendations for these thyroid cancers of intermediate differentiation. Conclusions Although some variation exists within the group, aggressive surgical and medical management are recommended for these neoplasias. Any such recommendations should, however, be viewed in the light of the fact that the current literature mainly consists of case reports, case series, and limited reviews. The clinical presentation, pathophysiology, diagnosis, and surgical and medical management for these thyroid cancers with intermediate differentiation are discussed.     

Papillary Thyroid Microcarcinoma: An Over-Treated Malignancy?

Background

The clinical importance of papillary thyroid microcarcinoma (PTMC) remains controversial, with current guidelines suggesting that thyroid lobectomy alone is sufficient. The purpose of this study was to identify population-level treatment patterns in the USA for PTMC.

Methods

Patients with PTMC in SEER (1998–2010) were included; demographic, clinical (extent of surgery, administration of post-operative radioactive iodine [RAI]), and pathologic characteristics were examined. Outcomes of interest were 5- and 10-year overall survival (OS) and disease-specific survival (DSS).

Results

The cohort consisted of 29,512 patients. Mean age at diagnosis was 48.5 years; mean tumor size was 0.53 cm. Overall, 73.4 % of patients underwent total thyroidectomy, and RAI was administered to 31.3 %. In multivariate analysis, total thyroidectomy was more frequently performed in patients with multifocal (odds ratio [OR] 2.55), ‘regional’, or ‘distant’ PTMC (OR 2.90 and 2.59). Non-operative management was associated with male patients (OR 4.24) and those aged ≥65 years (OR 6.31). Post-operative RAI was associated with multifocal PTMC (OR 2.57). Overall, 5- and 10-year DSS was 99.6 and 99.3 %, respectively, with no difference in DSS between patients who underwent partial versus total thyroidectomy. OS of patients with PTMC who underwent any thyroid operation was similar to that of the general population of the USA.

Conclusions

An increasing number of patients are undergoing total thyroidectomy and RAI for PTMC. While there may be a subset of patients for whom more aggressive therapy is indicated, many patients with PTMC may be over-treated, with no demonstrable benefit to survival.     

Differentiated Thyroid Cancer: “Complete” Rational Approach

Controversy continues regarding the optimal management of patients with differentiated thyroid cancer because no prospective randomized studies evaluating the merits of (1) extent of thyroidectomy, (2) postoperative radioactive iodine ablation, or (3) thyroid-stimulating hormone (TSH) suppressive therapy exist. Patients with low risk differentiated thyroid cancer enjoy a relatively good prognosis with a mortality rate of about 2% to 5% and a recurrence rate of about 20%. Despite the excellent prognosis in patients considered to be at low risk, total or near-total thyroidectomy in patients with differentiated thyroid cancer has the advantages that: (1) postoperative radioactive iodine can be used to detect and treat residual normal thyroid tissue and local or distant metastases; (2) follow-up serum thyroglobulin levels are a more sensitive marker of persistent or recurrent disease when all thyroid tissue has been removed; and (3) total or near-total thyroidectomy with postoperative ¹³¹I ablation and TSH suppressive therapy is associated with better survival and lower recurrence rates. Patients with occult papillary thyroid cancer and minimally invasive follicular thyroid cancer can be treated by thyroid lobectomy because they have a near-normal life expectancy. Virtually all other patients with differentiated thyroid cancer appear to benefit from more extensive initial treatment.     

Langerhans Cell Histiocytosis of Thyroid—A Diagnostic Dilemma

Langerhans cell histiocytosis (LCH) is a rare disease of antigen presenting cells and involvement of thyroid is really uncommon. The thyroid if involved is usually seen in multisystem disease but isolated thyroid involvement is very rare. The diagnosis of Langerhans cell histiocytosis of the thyroid is very challenging due to its rarity and is usually misdiagnosed as benign goiters, undifferentiated carcinoma, lymphoma, etc. Management of Langerhans cell histiocytosis of the thyroid also remains controversial. Prognosis in an isolated Langerhans cell histiocytosis of the thyroid is usually good but as it may precede a multisystem involvement, prolonged follow-up is required. We present a rare case of Langerhans cell histiocytosis of the thyroid, with variable diagnoses on fine needle aspiration cytology.     

Does Familial Non-Medullary Thyroid Cancer Adversely Affect Survival?

Background Familial non-medullary thyroid cancer (FNMTC) is associated with a higher rate of multifocality and a higher recurrence rate than sporadic thyroid cancer. However, the effect of FNMTC on life expectancy is unknown. Material and Methods Using data from our FNMTC database, we calculated life expectancy and survival rates after diagnosis of FNMTC and compared the results with the rates for unaffected family members and for the standard US population. Overall life expectancy and survival rates were calculated using the Kaplan–Meier method. We compared patients from families with 2 affected members with patients from families with ≥3 affected members. We also compared patients diagnosed in a known familial setting (index cases and subsequent cases) with patients diagnosed before the familial setting was recognized. Results There were 139 affected patients with 757 unaffected family members. The mean age at diagnosis was 40.8 ± 13.9 years and the mean follow-up time was 9.4 ± 11.7 years. Ten patients died of thyroid cancer during follow-up. The life expectancy of patients with FNMTC was similar to that of their unaffected family members. Survival was significantly shorter for patients with 3 or more affected family members, for patients diagnosed before the familial setting was recognized, and for patients with anaplastic cancer. Conclusions Our results suggest that FNMTC may be more aggressive than sporadic thyroid cancer, particularly in families with 3 or more affected members. However, when recognized and treated appropriately, it does not significantly shorten the overall life expectancy of the affected patients. Frederic Triponez, MD, is supported in part by a grant from the University Hospital of Geneva, Switzerland.     

Thyroid Cancer: Is the Incidence Still Increasing?

Background: The objective of this study was to define the epidemiology of thyroid cancer in our regional population and compare results with Surveillance, Epidemiology, and End Results (SEER) Program cancer registry trends.Methods: Thyroid cancer cases diagnosed between 1990 and 2000 were identified in the Florida Cancer Data System (FCDS). Overall, gender-specific, age-specific, and stage-specific incidence rates were calculated. All rates are per 100,000 and age-adjusted to the 2000 U.S. standard population. Estimated Annual Percent Change (EAPC) was calculated with a linear least-squares model.Results: Patients with thyroid cancer (n = 8603) were identified in the FCDS registry. Age-adjusted incidence rates increased from 4.2 per 100,000 to 7 per 100,000 in 2000. The EAPC for this period was 5.5% (P < .001). The SEER incidence rates increased from 7.9 to 10.2 per 100,000, and the EAPC was 3.7% (P < .05). Analysis of gender-specific incidence rates showed increases from 6 and 2.2 per 100,000 in 1990 to 10.1 and 3.8 per 100,000 in 2000 among females and males, respectively, with EAPCs of 5.9% (females) and 4.5% (males) (P < .001). With stratification by age group, the highest incidence rates were 9 per 100,000 in the group aged 65 to 84 years and 8.4 per 100,000 in the group aged 45 to 64 years.Conclusions: Thyroid cancer incidence rates in Florida almost doubled over the 1990–2000 period and are concordant with SEER trends. Etiologic studies addressing temporal changes in reproductive factors, more intensive diagnostic activities, and changes in histological criteria are warranted.     

Thyroid Hormones: Beneficial or Deleterious for Bone?

The mechanism of action as well as the clinical effects of thyroid hormones on bone has been of interest for more than a century. With the appearance of new treatment modalities for thyroid function disorders, the accompanying alterations in bone metabolism appeared to be rare. However, the introduction of new diagnostic tools, such as osteodensitometry and biochemical bone markers, has changed our view since they were able to show smaller but important changes in bone mineral metabolism associated with thyroid function disorders. Now, we know that hyperthyroidism is associated with an increased life-time risk for fractures, even after achieving euthyroidism. This fact may play an important role in the higher mortality rate among previously hyperthyroid patients later in life. Subclinical hyperthyroidism may also affect bone density, however, its effect on fracture rate remains to be established. The lack of thyroid hormones will alter normal growth during childhood. Adult hypothyroid patients tend to exhibit higher than normal bone density. Despite rather increased bone quantity, hypothyroidism is accompanied with increased fracture risk before and after diagnosis. The effect of thyroid hormone treatment on bone tissue is somewhat controversial. Nevertheless, only patients with suppressed thyroid-stimulating hormone (TSH) appear to loose bone and have higher fracture incidence, whereas patients with a TSH level in the normal range seem to have similar bone mineral content and fracture rate as euthyroid subjects. In summary, most of thyroid function disorders may result in reduced bone density and/or increased fracture rate that should be taken into consideration at clinical evaluation.     

Round Pendant Around the Neck–Thyroid. A Review

The rare situation of thyroid stone is discussed with literature review and case report. A case of isolated solitary stone of the thyroid is documented here. There are incidences of calcification in the thyroid gland commonly associated with carcinoma thyroid and multinodular goiter. But solitary stone of thyroid is reported rarely and one such case is reported from India. The possibility of malignancy is high, in case of calcification of thyroid swellings. Hence, isolated calcification should be surgically treated even if fine needle aspiration cytology is negative for malignancy.     

FDG-PET Detected Thyroid Incidentalomas: Need for Further Investigation?

Background Incidental thyroid abnormalities are increasingly detected in patients undergoing PET scans. The aim of this study was to review our experience with the management of PET detected thyroid incidentalomas in a large single institution series. Methods All PET scans performed from May 2003 to July 2005 were reviewed and patients with incidental thyroid abnormalities were identified. From this group, patients that underwent further investigation were analyzed. Data relating to PET scan findings, FNA diagnoses, operative details, and histopathology was reviewed. Results In 8,800 patients, 16,300 PET scans were performed of whom 263 patients (2.9% of patients and 1.6% of PET scans) had findings positive for thyroid abnormality. Thyroid malignancy was noted in 42% (24 patients) of the 57 patients that underwent FNA. In the group of 27 patients that were subjected to operative intervention, 74% (20 patients) were noted to have a malignant diagnosis. The final histopathology revealed primary thyroid carcinoma in all these 20 patients (19 patients with papillary carcinoma and one patient with primary thyroid lymphoma). The factors that correlated with an increased risk of malignancy were the presence of physical finding (p = 0.01) and focal (p < 0.01) or unilateral uptake (p < 0.01) on PET scan. The average SUV was not useful in differentiating benign (9.2) from malignant lesions (8.2, p = 0.7). Conclusions PET detected incidental thyroid abnormalities are rare. In patients with positive PET scan findings and suspicious features, the incidence of primary thyroid malignancy is very high. These patients warrant further investigation followed by possible operative intervention.     

Micromedullary Thyroid Cancer: How Micro Is Truly Micro?

Background  

The aggressive nature of medullary thyroid cancer (MTC) is evidenced by its propensity to present early with lymph node (LN) metastases. The clinical significance of sporadic MTC ≤1 cm (micro-MTC) is not clearly defined.     

How Many Contralateral Papillary Thyroid Carcinomas Can Be Missed?

Background

When surgeons decide to perform lobectomy as the treatment of papillary thyroid carcinomas (PTCs), they must consider the possibility of contralateral cancer. We wanted to determine the incidence of bilateral PTCs (bPTCs) and analyze their characteristics. We also wanted to determine how many patients with bPTC were missed preoperatively.

Methods

From January 2007 to May 2011, a total of 466 patients with PTC who were treated by total thyroidectomy at a single institution were enrolled. Patients were divided into two groups based on bilaterality. The patients with bPTCs were further investigated regarding the preoperative presence of the contralateral tumor.

Results

Bilaterality was seen in 29.8 % of PTC patients. In all, 36.8 % of PTCs ≥1 cm, and 25.7 % were papillary thyroid microcarcinomas (PTMCs). The presence of PTC in the contralateral lobe was missed in 15.8 % of bPTCs and in 21.3 % of bPTMCs. The rates of preoperatively nondetected contralateral cancer were 4.7 and 5.5 % for PTCs and PTMCs, respectively. Tumor size and multifocality were factors associated with bilaterality (p = 0.014 and p < 0.001, respectively).

Conclusions

Bilaterality is found more frequently when the tumor is large. Multifocality also can help predict the possibility of bilaterality. Therefore, total thyroidectomy may be necessary for patients with a multifocal or large tumor. It should be noted that the presence of a contralateral cancer is missed in 4.7 and 5.5 % of patients with preoperatively diagnosed unilateral PTC and PTMC, respectively.     

Do Benign Thyroid Nodules Have Malignant Potential? An Evidence-Based Review

Background  Benign thyroid tumors account for most nodular thyroid disease. Determination of whether a thyroid nodule is benign or malignant is a major clinical dilemma and underlies the decision to proceed to surgery in many patients. Although the accuracy of thyroid nodule fine-needle aspiration (FNA) has reduced the need for surgery over the years, questions regarding how to follow FNA-designated benign nodules remain unresolved. This is true at least in part because of uncertainty over whether some benign nodules harbor malignant potential. Methods  An evidence-based review of recent clinical, pathologic, and molecular data is presented. A summary of data and observations from our own experience is also provided. Results  Review of our recent 10-year experience indicates that 2% of thyroid malignancies arise within a preexisting benign thyroid nodule. In addition, both cytologic and molecular tumor markers, including Gal-3, CITED1, HBME-1, Ras, RET/PTC, and PAX8/PPARγ, have been identified in some histopathologically classified benign nodules. Gene expression profiling suggests that follicular adenomas and Hürthle cell adenomas have similarities to both benign and malignant tumors, suggesting that some of these tumors are premalignant. In addition, 10% of surgically excised follicular tumors are encapsulated follicular lesions with nuclear atypia, which have been termed “well-differentiated tumors of uncertain malignant potential.” The data available suggest that these tumors could be precursors to carcinoma. Conclusion  Some benign thyroid nodules have malignant potential. Further molecular testing of these tumors can shed light on the pathogenesis of early malignant transformation.     

Does Bethesda Category Predict Aggressive Features in Malignant Thyroid Nodules?

Background

It has been speculated that the Bethesda Classification System for thyroid fine-needle aspirate (FNA) may be used to predict aggressive features among histologically proven malignancies. We sought to evaluate whether malignancies that were characterized as Bethesda category V or VI have more aggressive features than malignancies that were category III or IV.

Methods

A prospectively maintained database was reviewed to identify thyroid malignancies treated at a single center from 2004 to 2009. Only cancers that could be definitively matched to a preoperative FNA were included. Associations between Bethesda category, patient demographics, histopathologic findings, and outcomes were examined.

Results

A total of 360 cancers were analyzed: 73 (20 %) were Bethesda category III or IV and 287 (80 %) were category V or VI. The majority of Bethesda III and IV cancers were follicular variants of papillary thyroid carcinoma (fvPTC), whereas the majority of Bethesda V and VI cancers were classic PTC (52 and 67 %, respectively, p < 0.01). Extrathyroidal extension (30 vs. 16 %, p = 0.02), lymph node metastases (50 vs. 31 %, p = 0.05), and multifocality (51 vs. 37 %, p = 0.03) were more common among Bethesda V and VI nodules. However, when Bethesda III or IV classic PTC and fvPTC were compared to Bethesda V or VI cancers of the same histologic subtype, there were no differences in any features. Recurrence and overall survival were the same in all groups.

Conclusions

Bethesda category may help to predict the most likely histologic subtype of thyroid cancer, but it does not have any prognostic significance once the histologic diagnosis is known.     

Predictive Factors of Thyroid Cancer in Patients with Graves’ Disease

Background

The best preoperative examination in Graves’ disease with thyroid cancer still remains uncertain. The objectives of the present study were to investigate the prevalence of thyroid cancer in Graves’ disease patients, and to identify the predictive factors and ultrasonographic features of thyroid cancer that may aid the preoperative diagnosis in Graves’ disease.

Methods

This retrospective study included 423 patients with Graves’ disease who underwent surgical treatment from 2002 to 2012 at our institution. The clinical features and ultrasonographic findings of thyroid nodules were recorded. The diagnosis of thyroid cancer was determined according to the pathological results.

Results

Thyroid cancer was discovered in 58 of the 423 (13.7 %) surgically treated Graves’ disease patients; 46 of those 58 patients had thyroid nodules, and the other 12 patients were diagnosed with incidentally discovered thyroid carcinomas without thyroid nodules. Among the 58 patients with thyroid cancer, papillary microcarcinomas were discovered in 50 patients, and multifocality and lymph node involvement were detected in the other 8 patients. Multivariate regression analysis showed younger age was the only significant factor predictive of metastatic thyroid cancer. Ultrasonographic findings of calcification and intranodular blood flow in thyroid nodules indicate that they are more likely to harbor thyroid cancers.

Conclusions

Because the influencing factor of metastatic thyroid cancers in Graves’ disease is young age, every suspicious nodule in Graves’ disease patients should be evaluated and treated carefully, especially in younger patients because of the potential for metastasis.