Ultrasonographic Thyroid Nodule Classification Using a Deep Convolutional Neural Network with Surgical Pathology.

Ultrasonography with fine-needle aspiration biopsy is commonly used to detect thyroid cancer. However, thyroid ultrasonography is prone to subjective interpretations and interobserver variabilities. The objective of this study was to develop a thyroid nodule classification system for ultrasonography using convolutional neural networks. Transverse and longitudinal ultrasonographic thyroid images of 762 patients were used to create a deep learning model. After surgical biopsy, 325 cases were confirmed to be benign and 437 cases were confirmed to be papillary thyroid carcinoma. Image annotation marks were removed, and missing regions were recovered using neighboring parenchyme. To reduce overfitting of the deep learning model, we applied data augmentation, global average pooling. And 4-fold cross-validation was performed to detect overfitting. We employed a transfer learning method with the pretrained deep learning model VGG16. The average area under the curve of the model was 0.916, and its specificity and sensitivity were 0.70 and 0.92, respectively. Positive and negative predictive values were 0.90 and 0.75, respectively. We introduced a new fine-tuned deep learning model for classifying thyroid nodules in ultrasonography. We expect that this model will help physicians diagnose thyroid nodules with ultrasonography.

Postoperative Thyroid-Stimulating Hormone Levels Did Not Affect Recurrence after Thyroid Lobectomy in Patients with Papillary Thyroid Cancer.

BACKGROUND: Thyroid-stimulating hormone (TSH) suppression is recommended for patients who undergo thyroidectomy for differentiated thyroid cancer (DTC). However, the impact of TSH suppression on clinical outcomes in low-risk DTC remains uncertain. Therefore, we investigated the effects of postoperative TSH levels on recurrence in patients with low-risk DTC after thyroid lobectomy. METHODS: Patients (n=1,528) who underwent thyroid lobectomy for papillary thyroid carcinoma between 2000 and 2012 were included in this study. According to the mean and dominant TSH values during the entire follow-up period or 5 years, patients were divided into four groups (<0.5, 0.5 to 1.9, 2.0 to 4.4, and ≥4.5 mIU/L). Recurrence-free survival was compared among the groups. RESULTS: During the 5.6 years of follow-up, 21 patients (1.4%) experienced recurrence. Mean TSH levels were within the recommended low-normal range (0.5 to 1.9 mIU/L) during the total follow-up period or 5 years in 38.1% or 36.0% of patients. The mean and dominant TSH values did not affect recurrence-free survival. Adjustment for other risk factors did not alter the results. CONCLUSION: Serum TSH levels did not affect short-term recurrence in patients with low-risk DTC after thyroid lobectomy. TSH suppression should be conducted more selectively.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery.

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to "surgical management of oral cancer" published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient's treatment goals.

Extent of surgery did not affect recurrence during 7-years follow-up in papillary thyroid cancer sized 1-4 cm: Preliminary results.

OBJECTIVE: There is debate whether hemithyroidectomy is sufficient for patients with papillary thyroid cancer (PTC) sized 1-4 cm. Therefore, we investigated whether hemithyroidectomy affects recurrence rate compared with thyroidectomy in patients with PTC sized 1-4 cm. DESIGN: Retrospective observational study. PATIENTS: We included 147 patients with 1-4 cm PTC who underwent hemithyroidectomy between 2004 and 2008. They were matched with 298 patients who underwent thyroidectomy, comparing age, sex, tumour size, multiplicity, extrathyroidal extension status and lymph node (LN) metastasis status. MEASUREMENTS: Recurrence-free survival (RFS) was compared between hemithyroidectomy and thyroidectomy groups. RESULTS: Median follow-up length was 7 years, during which there were nine (6.1%) and 17 (5.7%) recurrences in hemithyroidectomy and thyroidectomy groups, respectively. Recurrence-free survival in the hemithyroidectomy group was not different from that in the thyroidectomy group regardless of variant, multifocality, LN metastasis and radioactive iodine treatment. However, in subgroup analysis, hemithyroidectomy significantly increased the risk of recurrence in patients with contralateral nodules on the preoperative imaging. CONCLUSIONS: Recurrence after hemithyroidectomy was not different from that after thyroidectomy during a median follow-up of 7 years. However, because thyroidectomy might be favoured in patients with contralateral nodules at preoperative evaluation, a thorough evaluation of the contralateral thyroid lobe is necessary.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery.

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Comparison of quality of life between open and endoscopic thyroidectomy for papillary thyroid cancer.

BACKGROUND: Recently, various endoscopic thyroidectomy techniques have been introduced for cosmetic purposes. However, few reports have compared the quality of life (QOL) between post-endoscopic thyroidectomy and post-conventional open thyroidectomy. In this study, we investigated whether endoscopic thyroidectomy was comparable to conventional open thyroidectomy with respect to QOL. METHODS: Between January 2010 and September 2011, 75 patients underwent endoscopic thyroid lobectomy and 233 patients underwent conventional open thyroid lobectomy. The QOL was assessed preoperatively and at 1, 3, and 6 months postoperatively by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30-question (EORTC-QLQ-C30) instruments. RESULTS: Both groups showed similar changes over time in most of the QOL scales. However, patients who underwent endoscopic thyroidectomy showed significantly greater improvement in emotional function at 1 month (p = .039) and physical function at 3 months (p = .032). However, the pain increased more in the patients who underwent endoscopic thyroidectomy at 1 month (p = .042). CONCLUSION: Current findings suggest that endoscopic thyroidectomy may offer more rapid recovery of emotional and physical function than open thyroidectomy. © 2015 Wiley Periodicals, Inc. Head Neck 38: E827-E831, 2016.

Vitamin D level is not a predictor of hypocalcemia after total thyroidectomy.

PURPOSE: As the incidence of thyroid cancer has increased, hypocalcemia, a common complication of thyroid surgery, has become a serious problem. However, no definite predictor of postoperative hypocalcemia is known. In this study, our purpose was to investigate the potential role of vitamin D as a predictor of postoperative hypocalcemia. METHODS: A prospective observational study was performed on patients who underwent total thyroidectomy for thyroid cancer performed by a single experienced surgeon between October 2013 and September 2014. MEASUREMENTS: Their serum 25-OH vitamin D levels were measured preoperatively. On the day after surgery, serum calcium and intact parathyroid hormone levels were measured, and symptoms of hypocalcemia were recorded. RESULTS: Of the 134 patients, laboratory and symptomatic hypocalcemia developed in 52 patients (39 %) and 25 patients (19 %), on the day after surgery. The preoperative vitamin D level was 16.5 ± 9.2 ng/mL, and this value did not differ according to laboratory or symptomatic hypocalcemia (p = 0.94). The incidence of laboratory or symptomatic hypocalcemia did not differ according to vitamin D deficiency. Only incidental parathyroidectomy was associated with symptomatic hypocalcemia (p = 0.03). CONCLUSIONS: Vitamin D level is not a predictor of hypocalcemia after total thyroidectomy for thyroid cancer. Thus, routine preoperative screening for vitamin D is not recommended.

Central lymph node metastasis in papillary thyroid microcarcinoma can be stratified according to the number, the size of metastatic foci, and the presence of desmoplasia.

BACKGROUND: Lymph node (LN) metastasis is common in papillary thyroid microcarcinoma (PTMC). The aim of this study was to investigate the impact of LN metastasis and its risk stratification on PTMC recurrence. METHODS: We retrospectively reviewed the data of 336 patients with PTMC who underwent surgery from 2005 to 2006 at a single institution. LN metastasis was stratified according to the number of metastatic LNs, the ratio of metastatic to removed LNs, the size of metastatic foci in LNs, and the presence of extranodal extension and desmoplasia. RESULTS: Of the 336 patients, 93 (28%) had LN metastasis. During the follow-up of 5.3 years, 16 (4.8%) experienced locoregional recurrence. Among several clinicopathologic factors, LN metastasis was the most important risk factor for recurrence (P = .02). Lateral LN metastasis was correlated with recurrence-free survival (P < .01), whereas central LN metastasis was not (P = .20). When central LN metastasis was stratified, a high number of metastatic LNs (≥3), larger metastatic foci (≥0.2 cm), and the presence of desmoplasia were associated with recurrence-free survival (P < .05). CONCLUSION: The prognostic significance of central LN metastasis can differ according to the number of metastatic LNs, the size of metastatic foci, and the presence of desmoplasia. Patients with a high number of metastatic LNs, larger metastatic foci, and presence of desmoplasia in LNs should be treated aggressively and supervised carefully for PTMC recurrence.

Loss of ERß expression in papillary thyroid carcinoma is associated with recurrence in young female.

OBJECTIVES: We investigated the expression of oestrogen receptors (ERs) in papillary thyroid cancers (PTCs) and evaluated their prognostic role. METHODS: We enrolled 81 female patients who underwent thyroid surgery and had a confirmed diagnosis of PTC between 01 January 1995 and 31 December 1996. Data on clinicopathologic parameters were obtained from patients' medical records. Tissue paraffin blocks of these 81 patients were collected for immunohistochemistry for ERα and ERß. RESULTS: ERα expression was observed in only eight patients (9·9%). In contrast, ERß expression was positive in 36 (44·4%) patients. Total thyroidectomy (84·4% vs 61·1%, P = 0·017) and cervical lymph node metastasis (62·2% vs 22·2%, P = 0·000) were more frequent in the ERß-negative group than in the ERß-positive group. Among younger female patients (<45 years), the ERß-negative group showed a tendency towards more frequent recurrent or persistent disease than the ERß-positive group (42·3% vs 13·6%, P = 0·029). In contrast, the ERα-positive group showed more recurrent or persistent disease than the ERα-negative group in older female patients (100% vs 24·1%, P = 0·024). In multivariate analysis, ERß negativity, extrathyroidal invasion and radioactive iodine treatment were risk factors for recurrence in young female patients. CONCLUSION: Loss of ERß expression was associated with recurrence in young female PTC patients. This finding suggests that oestrogen might play a protective role in the progression of PTC via ERß, especially in young female patients.

Preoperative localization and intraoperative parathyroid hormone assay in korean patients with primary hyperparathyroidism.

BACKGROUND: The intraoperative parathyroid hormone (IOPTH) assay is widely used in patients with primary hyperparathyroidism (PHPT). We investigated the usefulness of the IOPTH assay in Korean patients with PHPT. METHODS: We retrospectively reviewed the data of 33 patients with PHPT who underwent parathyroidectomy. Neck ultrasonography (US) and 99mTc-sestamibi scintigraphy (MIBI scan) were performed preoperatively and IOPTH assays were conducted. RESULTS: The sensitivity of neck US and MIBI scans were 91% and 94%, respectively. A 50% decrease in parathyroid hormone (PTH) levels 10 minutes after excision of the parathyroid gland was obtained in 91% (30/33) of patients and operative success was achieved in 97% (32/33) of patients. The IOPTH assay was 91% true-positive, 3% true-negative, 0% false-positive, and 6% false-negative. The overall accuracy of the IOPTH assay was 94%. In five cases with discordant neck US and MIBI scan results, a sufficient decrease in IOPTH levels helped the surgeon confirm the complete excision of the parathyroid gland with no additional neck exploration. CONCLUSION: The IOPTH assay is an accurate tool for localizing hyperfunctioning parathyroid glands and is helpful for evaluating cases with discordant neck US and MIBI scan results.

Comparative study of a gasless transaxillary approach versus a bilateral axillo-breast approach for endoscopic thyroidectomy in a single institute.

BACKGROUND: Gasless transaxillary approach (TA) and the bilateral axillo-breast approach (BABA) are 2 distinctive approaches for endoscopic thyroidectomy. The purpose of this study was to evaluate and compare these 2 procedures. METHODS: From May 2008 to July 2011, we performed endoscopic hemithyroidectomy via gasless TA (83 cases) and BABA (45 cases). The following variables were evaluated: operation time, postoperative pain score, drainage amount, drainage day, postoperative complications, and cosmetic satisfaction score. RESULTS: There were no significant differences between the 2 approaches in terms of clinicopathologic characteristics and surgical outcomes, except for postoperative pain and cosmetic satisfaction. As for postoperative pain and cosmetic satisfaction, the gasless TA group complained of less pain and the BABA group had a better cosmetic outcome. CONCLUSION: These findings will contribute to providing guidelines for the choice of surgeons between gasless TA and BABA techniques for endoscopic thyroidectomy.

New endoscopic thyroidectomy via a unilateral axillo-breast approach with gas insufflation: Preliminary report.

BACKGROUND: Invasiveness of endoscopic thyroidectomy has been in debate. The purpose of this study was to introduce new endoscopic thyroidectomy via a unilateral axillo-breast approach (UABA) with gas insufflation to lessen invasiveness. METHODS: We performed 68 cases of hemithyroidectomy via a UABA with gas insufflation from January to July 2011. The following variables were studied: operation time, pain score, drainage amount, drainage day, perioperative complications, pathological outcomes, and cosmetic satisfaction. RESULTS: Mean postoperative pain visual analogue scale (VAS) scores were 2.75 ± 0.93 and 2.07 ± 0.79 at 1 and 3 days after surgery. The mean amount of drainage over the first 3 postoperative days was 144.35 ± 51.64 mL, and the mean time to drain removal was 3.75 ± 0.81 days. Two cases (2.9%) of transient vocal cord palsy and 2 cases (2.9%) of seroma were identified. All patients were satisfied with the cosmetic results. CONCLUSION: Endoscopic thyroidectomy via a UABA with gas insufflation is a feasible and less invasive option for selected patients.

Role of adjuvant chemotherapy in malignant mucosal melanoma of the head and neck.

The objective of this study was to analyze the role of adjuvant chemotherapy and prognostic factors in malignant mucosal melanoma of the head and neck (HNMM). Thirty-two patients with mucosal melanoma of the head and neck who received local treatment with or without adjuvant chemotherapy were reviewed. Clinicopathologic parameters including anatomic sites, gender, age (60 vs.>60years), stage, level of invasion, p53 and MDM2 [murine double minute 2] expressions, performance status, and adjuvant chemotherapy were evaluated. The patients' median age was 62years, and 16 (50%) received adjuvant chemotherapy. Expressions of p53 and MDM2 were demonstrated in six of 24 and three of 26 cases, respectively. Predictors of poor survival according to univariate analysis were level of invasion and anatomic location of the primary tumor. Patients who received adjuvant chemotherapy had prolonged survival (p=0.002), which was also shown in the multivariate Cox regression model (HR, 0.24; p=0.014). Our analysis suggests a significant role of adjuvant chemotherapy and different patterns of p53 and MDM2 expression in HNMM relative to cutaneous melanomas. However, since this study is retrospective and observational, with a small sample size, further studies are needed to confirm the definitive role of adjuvant chemotherapy in the treatment of malignant mucosal melanoma of the head and neck.

Stereotactic body radiotherapy for refractory cervical lymph node recurrence of nonanaplastic thyroid cancer.

OBJECTIVE: To investigate the feasibility and efficacy of stereotactic body radiotherapy as salvage treatment for cervical node recurrence from nonanaplastic thyroid cancer refractory to other modalities. STUDY DESIGN: Pilot study. SETTING: A single institution-based practice. SUBJECTS AND METHODS: Between August 2002 and November 2007, nine patients with recurrent nonanaplastic thyroid cancer were treated with stereotactic body radiotherapy for nodal metastases. Radiotherapy was delivered in one to three fractions, and the median dose was 36 Gy (range 30-39 Gy). RESULTS: Twenty-nine nodes in nine patients were treated. Seven patients had papillary carcinoma, and two had medullary carcinoma. These patients developed nodal recurrence after they received salvage surgery and/or radioisotope (RI) treatment for recurrent thyroid cancer. All nodes were in the cervical or supraclavicular areas, excepting one hilar node. Retropharyngeal node metastases were present in five patients. The median follow-up period was 23 months (range 4-63 mo). No local progression was observed in nodes treated by stereotactic body radiotherapy. Four patients developed new metastases in nontarget regional nodes after radiotherapy, and in two of these, regional failure was salvaged by additional stereotactic body radiotherapy. No serious adverse events were observed in any patient. CONCLUSION: In select patients, stereotactic body radiotherapy may be a feasible option for treating refractory nodal recurrence from nonanaplastic thyroid cancer. Further studies are necessary to define the role of stereotactic body radiotherapy in the management of thyroid cancer.

EGFR mutations and human papillomavirus in squamous cell carcinoma of tongue and tonsil.

This study was performed to determine the clinical significance of mutations in the EGFR (epidermal growth factor receptor) along with their association with human papillomavirus (HPV) infections in patients with squamous cell carcinoma of the head and neck (HNSCC). Exons 18-21 of the EGFR tyrosine kinase domain were sequenced and HPV typing was carried out using the HPV DNA chip in tissues obtained from patients with tongue and tonsil cancer. Univariate and multivariate analyses were used to identify the significant factors. One hundred and eight patients were enrolled. Ten patients (9%) were HPV positive and 17 (16%) had EGFR mutations. None of the patients with EGFR mutations were HPV positive. Gender, age (<60 years versus 60 years), and smoking history were not associated with EGFR mutations. A higher percentage of patients with tonsillar cancer were HPV positive than those with tongue cancer (26% and 0%, respectively; P<0.001). EGFR mutations were not a significant prognostic factor (P=0.746). HPV-positive patients had prolonged survival (P=0.025). Multivariate analysis revealed a longer overall survival in HPV-positive patients (P=0.007). EGFR mutations are not associated with the HPV-positive status, which may confer a better survival outcome. Clinical features of lung cancer patients with EGFR mutations were not observed in HNSCC. A further study will be needed to confirm these results.