Differences in long-term quality of life between hemithyroidectomy and total thyroidectomy in patients treated for low-risk differentiated thyroid carcinoma.

BACKGROUND: The long-term health-related quality-of-life implications of treating low-risk differentiated thyroid cancer with total thyroidectomy or hemithyroidectomy is important to patients but remains poorly understood. METHODS: Using a cross-sectional mailed survey, we compared long-term health-related quality-of-life in low-risk differentiated thyroid cancer survivors treated with hemithyroidectomy to those treated with total thyroidectomy between 2005 and 2016 at a university hospital. European Organisation for Research and Treatment of Cancer Quality of Life core Questionnaire version 3.0, the supplementary Thyroid Cancer specific questionnaire module version 2.0, and the Assessment of Survivor Concerns (ASC) questionnaires were used. Our primary outcome was the global scale of quality of life. Exploratory outcomes included differences among other health-related quality-of-life items corrected for potential confounders in multivariable regression analyses. RESULTS: The response rate was 51.0% (270 of 529), of which 59 patients (21.9%) were treated with hemithyroidectomy. Main outcome score global quality of life did not differ between groups (76.9 hemithyroidectomy vs 77.7 total thyroidectomy, P = .450). Exploratory analyses showed hemithyroidectomy to be associated with more worry about recurrence on the Assessment of Survivor Concerns questionnaire (2.4 hemithyroidectomy vs 2.1 total thyroidectomy, P = .021). CONCLUSION: Long-term quality of life was not significantly different between low-risk differentiated thyroid cancer patients treated with total thyroidectomy compared with hemithyroidectomy. In secondary analyses, worry about recurrence appeared to be higher in individuals treated with hemithyroidectomy. These data highlight previously unreported impact of surgical regimen to the health-related quality-of-life for low-risk differentiated thyroid cancer patients.

Preoperative Computed Tomography Changes Surgical Management for Clinically Low-Risk Well-Differentiated Thyroid Cancer.

BACKGROUND: In the current guidelines for differentiated thyroid cancer (DTC), computed tomography (CT) of the neck has a limited role. The authors hypothesized that adding CT to the workup of clinically low-risk DTC size 4 cm or smaller changes the surgical management for a portion of patients due to detection of clinically significant lymph node metastases not located by ultrasound of the neck. METHODS: A prospective cohort of DTC patients at an academic referral center between 2012 and 2016 was reviewed. All the patients with fine-needle aspiration cytopathology results suspicious for malignancy or malignant tumor (Bethesda category 5 or 6, respectively) underwent CT before surgery. Clinically low-risk DTC patients were selected if they had a tumor diameter of 4 cm or less and no evidence for local invasion or suspicious lymph nodes seen on ultrasound. Outcomes focused on alteration of the surgical plan based on CT and correlation with pathology. RESULTS: The CT findings for 25 (22.5%) of 111 patients with clinically low-risk DTC led to a change in surgical management. Of these 25 patients, 16 (14.4% of the entire cohort) benefited due to the removal of clinically significant lymph node disease not seen on ultrasound. Categorization of the group that had a change in management showed that 6 (85.7%) of 7 lateral neck dissections and 10 (55.6%) of 18 central neck dissections (CND) harbored metastatic nodes larger than 2 mm. CONCLUSIONS: In the group with clinically low-risk DTC, CT changed surgical management for a substantial number of the patients with clinically significant nodal disease not detected by ultrasound. This highlights the fact that in certain practice settings, adding CT to the preoperative staging may be favorable for the detection of nodal metastasis.

Papillary Thyroid Cancers with Focal Tall Cell Change are as Aggressive as Tall Cell Variants and Should Not be Considered as Low-Risk Disease.

BACKGROUND: The tall cell variant of papillary thyroid carcinoma (PTC) is as an aggressive histological variant. The proportion of tall cells needed to influence prognosis is debated. METHODS: Patients with PTC and tall cells, defined as having a height-to-width ratio of ≥ 3:1, seen at a high-volume center between 2001 and 2015, were reviewed. Specimens were classified as (1) focal tall cell change, containing < 30% of tall cells; (2) tall cell variant, ≥ 30% of tall cells; and (3) control cases selected from infiltrative classical PTCs without adverse cytologic features. Univariate, sensitivity, and multivariate analyses were performed with persistent/recurrent disease as the primary outcome. RESULTS: We identified 96 PTCs with focal tall cell change, 35 with the tall cell variant and 104 control cases. Factors associated with poor clinical prognosis were significantly greater in those with focal tall cell change and tall cell variants. Regarding primary outcome, hazard ratios were 2.3 (95% confidence interval [CI] 1.0-5.7) for focal tall cell change, and 3.4 (95% CI 1.2-8.7) for tall cell variants compared with controls. Five-year disease-free survival was higher for the control group (92.7%, CI 87.4-98.0) compared with focal tall cell change (76.3%, CI 66.1-86.5) and the tall cell variant (62.2%, CI 43.2-81.2). When stratified in groups consisting of tall cell proportions (< 10%, 10-19%, 20-29% and ≥ 30%), identification of ≥ 10% tall cell change was associated with worse outcome (p = 0.002). CONCLUSIONS: PTCs with ≥ 10% tall cell change have worse prognosis than those without tall cells. Our data indicate that thyroid cancer management guidelines should consider PTCs with focal tall cell change outside of the low-risk classification.

Clinical Safety of Renaming Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: Is NIFTP Truly Benign?

BACKGROUND: Renaming encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) to noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was recently suggested to prevent the overtreatment, cost and stigma associated with this low-risk entity. The purpose of this study is to document the incidence and further assess the clinical outcomes of reclassifying EFVPTC to NIFTP. METHODS: We searched synoptic pathologic reports from a high-volume academic endocrine surgery hospital from 2004 to 2013. The standard of surgical pathology practice was based on complete submission of malignant thyroid nodules along with the nontumorous thyroid parenchyma. Rigid morphological criteria were used for the diagnosis of noninvasive EFVPTC, currently known as NIFTP. A retrospective chart review was conducted looking for evidence of malignant behavior. RESULTS: One hundred and two patients met the strict inclusion criteria of NIFTP. The incidence of NIFTP in our cohort was 2.1% of papillary thyroid cancer cases during the studied time period. Mean follow-up was 5.7 years (range 0-11). Five patients were identified with nodal metastasis and one patient with distant metastasis. Overall, six patients showed evidence of malignant behavior representing 6% of patients with NIFTP. CONCLUSION: Our study demonstrates that the incidence of NIFTP is significantly lower than previously thought. Furthermore, evidence of malignant behavior was seen in a significant number of NIFTP patients. Although the authors fully support the de-escalation of aggressive treatment for low-risk thyroid cancers, NIFTP behaves as a low-risk thyroid cancer rather than a benign entity and ongoing surveillance is warranted.

Determining Patient Preferences for Indeterminate Thyroid Nodules: Observation, Surgery or Molecular Tests.

BACKGROUND: Gene-expression classifiers (GEC) and genetic mutation panels (GMP) have been shown to improve preoperative diagnostic evaluations of indeterminate thyroid nodules. Despite the improvement, uncertainty regarding the proper management exists. Patient preferences may better inform the management of these indeterminate thyroid nodules. METHODS: Hypothetical scenarios were administered to two groups of patients: those with previous FNA-confirmed indeterminate thyroid nodules (Group A, n = 50) and those presenting to a general otolaryngology clinic for other reasons (Group B, n = 50). We evaluated patient preferences for surgery, observation and the use of molecular tests while varying the risk of malignancy, cost and diagnostic properties of the tests. RESULTS: The mean threshold for choosing surgery over observation was a 38.6% risk of malignancy on FNA. When offered either GEC, GMP or both (with their inherent imperfect diagnostic properties) in addition to the indeterminate FNA, 85.0% of respondents picked at least one of the molecular tests over either observation or surgery if the test(s) were free of charge. However, only 51.7% of respondents chose at least one of the tests when asked to pay the current cost of the test(s) (p < 0.001). On multivariable analysis, sex, the presence of an indeterminate FNA diagnosis and income level significantly predicted the desire to proceed with a molecular test above standard management. CONCLUSION: Patient preferences for thyroid nodule management are dependent on the risk of malignancy, prognosis of cancer and costs. Patients prefer molecular tests over standard management with indeterminate thyroid nodules, but the costs of the test(s) reduce the desire.

Redefining classification of central neck dissection in differentiated thyroid cancer.

Therapeutic central neck dissection for differentiated thyroid cancer is recommended in the setting of clinically positive disease. The role of lymphadenectomy in patients with clinically negative disease is a matter of controversy and therefore extent of surgery varies. The boundaries of the central neck are variably described, as are the components of a central neck dissection. Patients with aggressive disease are managed with a comprehensive dissection, yet there is no classification system to distinguish this from a less rigorous operation. Therefore, there is variability in reporting and difficulty in the interpretation of results in the published literature. Here we propose a novel classification system for central neck dissection in thyroid cancer that allows accurate reporting of extent of surgery. The objectives are to reduce ambivalence and allow documentation of extent of lymphadenectomy, such that comparisons can be made between the varied strategies in the management of the central compartment.

Clinical librarian attendance at general surgery quality of care rounds (Morbidity and Mortality Conference).

Quality of Care rounds, also known as Mortality and Morbidity conferences, are an important and time-honored forum for quality audit in clinical surgery services. The authors created a modification to their hospital's Quality of Care rounds by incorporating a clinical librarian, who assisted residents in conducting literature reviews related to clinical topics discussed during the rounds. The objective of this article is to describe the authors' experience with this intervention. The clinical librarian program has greatly improved the Quality of Care rounds by aiding in literature searches and quality of up-to-date, evidence-based presentations.

Lymph node assessment in melanoma.

The surgical management of lymph nodes continues to be important in melanoma since effective systemic therapies are not available. Controversy exists around the significance of the early detection and management of microscopically positive lymph nodes detected by sentinel lymph node biopsy and this is the subject of current surgical clinical trials. Complete lymphadenectomy is recommended for lymph node metastases. The importance of proper surgical technique is discussed.

Lymphatic invasion identified by monoclonal antibody D2-40, younger age, and ulceration: predictors of sentinel lymph node involvement in primary cutaneous melanoma.

OBJECTIVES: To assess whether lymphatic invasion identified by immunostaining with monoclonal antibody (Mab) D2-40 in primary cutaneous melanomas correlates with other clinicopathologic factors and to assess whether lymphatic invasion is a potential predictor of sentinel lymph node (SLN) status. DESIGN: Retrospective case-series study. SETTING: Academic referral center. Patients Ninety-six consecutive patients with primary cutaneous melanomas 1 mm thick or greater with adequate pathologic material available for immunohistochemical studies and SLN biopsy. MAIN OUTCOME MEASURES: Association between lymphatic invasion identified by immunostaining with Mab D2-40 in primary cutaneous melanoma and correlation with the clinicopathologic features and the association of all of the factors with SLN status. RESULTS: Lymphatic invasion identified by immunostaining with Mab D2-40 was significantly associated with deeper Clark level of invasion (P < .001), and greater Breslow tumor thickness (P = .01) SLN positivity was identified in 23 of 96 cases (24%). At univariate analysis, younger age (P = .03), ulceration (P < .006), lymphatic invasion (P < .02), deeper Clark level of invasion (P < .008), Breslow tumor thickness (P = .008), and tumor site on the trunk (P = .02) were significantly associated with SLN metastases. At multivariate analysis, only younger age (P = .04), ulceration (P = .03), and lymphatic invasion detected by immunostaining with Mab D2-40 (P = .01) were significantly associated with SLN positivity. The probability of SLN positivity was 13% when all 3 independent prognostic factors yielded negative findings and increased to 61% when all 3 variables yielded positive findings. CONCLUSIONS: Breslow tumor thickness, Clark level of invasion, and tumor site on the trunk predicted SLN status at univariate analysis. Multivariate regression analysis showed that lymphatic invasion identified by immunostaining with Mab D2-40, younger age, and ulceration were the only independent prognostic factors. The most significant predictor of SLN metastasis was the positivity of all 3 independent prognostic factors (61%). Findings of this study suggest that assessment of lymphatic invasion by immunostaining with Mab D2-40 with other clinicopathologic factors can be used to identify patients who could be spared the need for SLN biopsy.

Thyroid scintigraphy in the assessment of the solitary thyroid nodule: differences in practice patterns between family physicians and specialists.

OBJECTIVE: It has been shown that there is considerable variation in the diagnosis and management of the thyroid nodule. The purpose of this study was to investigate the differences in the practice of family physicians and specialists in ordering thyroid scans in the initial workup of patients with thyroid nodules. DESIGN: Retrospective electronic and paper-based chart review. SETTING: University Health Network, Toronto. PARTICIPANTS: All patients who underwent thyroidectomy over a 2-year period. INTERVENTIONS: An audit of their preoperative diagnostic tests was performed, and the specialties of the ordering physicians were identified. RESULTS: One hundred ninety-four patients were assessed. Sixty-three patients (32.5%) were investigated exclusively by their family physician, 63 (32.5%) were investigated exclusively by a specialist, and 68 (35%) were investigated by both. Family physicians ordered thyroid scans in 51% of patients, whereas specialists ordered scans in 29% of patients (p<.001). The medical specialists ordered 36 scans (33.6%) in 107 patients, whereas the surgical specialists ordered 2 (8.3%) scans in 24 patients (p<.001). CONCLUSION: Despite the limited role for thyroid scans in the initial workup of a solitary thyroid nodule, they are still frequently ordered, particularly by family physicians. We recommend publication of Canadian evidence-based guidelines for the management of thyroid nodules, similar to existing American guidelines, which could help reduce the amount of unnecessary testing.

Extent of thyroidectomy is not a major determinant of survival in low- or high-risk papillary thyroid cancer.

BACKGROUND: The optimal extent of thyroidectomy for papillary thyroid cancer (PTC) is controversial. Our objective was to evaluate the effect of total thyroidectomy or partial thyroidectomy on survival in low- and high-risk patients. METHODS: The Surveillance, Epidemiology, and End Results database was used to identify PTC patients who underwent thyroidectomy. The independent effects of age, distant metastases, extrathyroidal extension, tumor size, sex, lymph node metastases, radioactive iodine use, and extent of thyroidectomy on survival were analyzed for low- and high-risk PTC. RESULTS: There were 4402 (81%) low-risk and 1030 (19%) high-risk patients; 84.9% underwent total thyroidectomy. The 5- and 10-year survival were 95% and 89% in the low-risk patients and 84% and 73% in the high-risk patients, respectively (P = .001). In the low-risk patients, 10-year survival after total thyroidectomy was 89%, compared with 91% after partial thyroidectomy (adjusted hazard ratio for death, 1.73; 95% confidence interval, 1.28-2.33; P < .001); older age, male sex, larger tumor, lymph node metastases, and lack of radioactive iodine were associated with higher mortality. In the high-risk patients, 10-year survival after total thyroidectomy was 72%, compared with 78% after partial thyroidectomy (adjusted hazard ratio for death, 1.46; 95% confidence interval, .89-2.40; P = .14); older age, distant metastases, larger tumors, and lack of radioactive iodine were associated with higher mortality. CONCLUSIONS: Survival of patients with PTC was not significantly influenced by the extent of thyroidectomy. The survival after partial thyroidectomy was similar to total thyroidectomy within both the low- and high-risk prognostic groups.

AMES prognostic index and extent of thyroidectomy for well-differentiated thyroid cancer in the United States.

BACKGROUND: The optimal extent of thyroidectomy for well-differentiated thyroid cancer is controversial. It has been suggested that surgeons use the Age, Metastases, Extent and Size (AMES) risk classification to decide between partial thyroidectomy (PT) or total thyroidectomy (TT). METHODS: The Surveillance, Epidemiology and End Results database was used to identify patients who underwent PT or TT for well-differentiated thyroid cancer between 1992 and 1997. Age, distant metastases, extrathyroidal extension, tumor size, AMES risk group, gender, histologic subtype, and lymph node metastases were analyzed by using logistic regression models to evaluate whether surgeons use these factors to determine extent of thyroidectomy. RESULTS: Of 9,226 patients, most patients had small cancers confined to the thyroid gland. Of these, 79.9% were AMES low-risk, and 83% underwent TT. Age 40 years or older (40 to 49 years: odds ratio [OR], 0.75, 95% confidence interval [CI], 0.65 to 0.86; 50 years or older: OR, 0.66; 95% CI, 0.58 to 0.75) was associated with a lower likelihood of TT, as were female gender (OR, 0.80; 95% CI, 0.70 to 0.92) and follicular histology (OR, 0.65; 95% CI, 0.55 to 0.78). Extrathyroidal extension (OR, 3.85; 95% CI, 3.09 to 4.80), regional lymph node metastases (OR, 6.98; 95% CI, 5.45 to 8.93), distant metastases (OR, 7.29; 95% CI, 2.69 to 19.8), AMES high-risk group (OR, 2.82; 95% CI, 2.36 to 3.38), and larger tumor size (OR, 1.27; 95% CI, 1.01 to 1.59) were associated with greater likelihood of TT. In multivariable analyses, only age, extrathyroidal extension, and regional and distant metastases were associated with extent of thyroidectomy; AMES risk group and tumor size were no longer significant. CONCLUSIONS: Most patients undergo TT for well-differentiated thyroid cancer regardless of AMES risk grouping. In contrast to AMES risk-group classification, younger patients are more likely to undergo TT compared with older patients. Although extrathyroidal extension and distant metastases were associated with TT in accordance with AMES criteria, tumor size had no independent influence. Regional lymph node metastasis, not an AMES criterion, increased the likelihood of TT. Some components of AMES risk-group classification are used by surgeons to choose the extent of thyroidectomy.

Computer-assisted evoked electromyography with stimulating surgical instruments for recurrent/external laryngeal nerve identification and preservation in thyroid and parathyroid operation.

BACKGROUND: The reported incidence of recurrent laryngeal nerve (RLN) palsy/paralysis in thyroid and parathyroid operation ranges from 2% to 13%. Injury to the external branch of the superior laryngeal nerve (EBSLN) is less clearly documented. We hypothesized that a novel evoked electromyography system using an audio warning alarm might be beneficial for detection and preservation of the RLN and EBSLN. METHODS: A total of 117 thyroid/parathyroid operations were performed using a nerve locator/monitor (Neurovision SE, RLN Systems Inc, Jefferson City, Mo). Dissection was performed using a stimulating hemostat with conduction to an endotracheal surface electrode. RESULTS: A total of 97 thyroidectomies (50 total, 47 lobectomies) and 20 parathyroidectomies (16 directed, 4 bilateral) were performed representing 176 RLN and 152 EBSLN at risk. Of 176 RLN, 161 were correctly identified by the nerve stimulator alarm including 2 nonrecurrent nerves. The cricothyroid space and the superior pole vessels were scanned to identify the EBSLN by observing for cricothyroideus contraction or an alarm. Fourteen of 152 (8.9%) cases of type 2 anatomy were suggested where meticulous dissection of superior pole vessels prevented EBSLN injury. CONCLUSIONS: Computer-assisted evoked electromyography with stimulating surgical instruments is a useful surgical tool. This technology may be especially useful in reoperation in dense scar tissue and preserving the EBSLN in thyroid operation.

Patient education and informed consent in head and neck surgery.

OBJECTIVE: To examine the effects of an educational intervention, in the form of printed material, on patient knowledge and recall of possible risks from parotidectomy or thyroidectomy. DESIGN: Prospective, randomized, controlled study conducted during a 9-month period. SETTING: Head and neck surgery clinic of an academic tertiary care hospital. PATIENTS: One hundred twenty-five consecutive patients older than 16 years who were undergoing thyroidectomy or parotidectomy at the head and neck surgery clinic were recruited. Four patients were excluded from analysis because their follow-up interview was not within the required limits. INTERVENTION: At the preoperative visit during the routine consent process, both groups received a verbally delivered checklist of risks specific for the surgery to be performed. The intervention group was also given a pamphlet with written information accompanied by illustrations. MAIN OUTCOME MEASURES: The effectiveness of the educational intervention was determined by comparing the average rate of risk recall between the intervention and control groups. The effects of age, sex, level of education, and time between the consent and recall interviews on recall rate were also assessed. RESULTS: The overall risk recall rate for both procedures was 39.1%. The recall rate of the intervention group was 50.3% compared with 29.5% for the control group (P<.001). CONCLUSIONS: The intervention consistently improved risk recall for all patients regardless of age, sex, and level of education. Patients' ability to recall potential risks was significantly increased by an educational intervention; all patients would benefit from this intervention.

Surgical procedure logging with use of a hand-held computer.

OBJECTIVE: To evaluate the feasibility of incorporating hand-held computing technology in a surgical residency program, by means of hand-held devices for surgical procedure logging linked through the Internet to a central database. SETTING: Division of General Surgery, University of Toronto. DESIGN: A survey of general surgery residents. METHODS: The 69 residents in the general surgery training program received hand-held computers with preinstalled medical programs and a program designed for surgical procedure logging. Procedural data were uploaded via the Internet to a central database. Survey data were collected regarding previous computer use as well as previous procedure logging methods. MAIN OUTCOME MEASURE: Utilization of the procedure logging system. RESULTS: After a 5-month pilot period, 38% of surgical residents were using the procedure-logging program successfully and on a regular basis. Program use was higher among more junior trainees. Analysis of the database provided valuable information on individual trainees, hospital programs and supervising surgeons, data that would assist in program development. CONCLUSIONS: Hand-held devices can be implemented in a large division of general surgery to provide a reference database and a procedure-logging platform. However, user acceptance is not uniform and continued training and support are necessary to increase acceptance. The procedure database provides important information for optimizing trainees' educational experience.

Underexpression of p27/Kip in thyroid papillary microcarcinomas with gross metastatic disease.

OBJECTIVE: Papillary microcarcinomas (PMCs) of the thyroid (measuring less than 1 cm in maximum dimension) are extremely common incidental histologic findings, and most of these tumors are not considered clinically significant. However, rare PMCs behave aggressively and metastasize early, giving rise to clinically significant metastatic disease. We hypothesized that p27 and MIB-1/Ki-67 immunoreactivity would allow us to identify this small subgroup of PMCs that have the potential to behave aggressively. METHODS: We reviewed the histopathology reports of 2000 patients who underwent thyroid surgery at our institution between 1995 and 1999 and identified 22 patients who presented with gross regional metastases from a primary PMC. The primary and metastatic tumors were stained for ret, p53, p27, and MIB-1 using the avidin-biotin-peroxidase complex technique. A control group of 33 nonmetastasizing PMCs was also analyzed. RESULTS: Immunoreactivity for ret, p53, and MIB-1 showed no difference between metastasizing and nonmetastasizing PMCs. In most tumors, ret was present, while p53 immunoreactivity was absent in all tumors. MIB-1 staining was present in a small number of cells in both groups of tumors. Immunoreactivity for p27 was quantitated by the intensity of expression as well as the distribution of positive cells within each tumor. All tumors showed lower p27 expression than normal thyroid tissue. However, metastasizing PMCs demonstrated a significantly lower expression of p27 than nonmetastasizing PMCs (P<.001). CONCLUSION: Our results suggest that p27 immunohistochemical analysis may be a valuable diagnostic tool in predicting aggressive potential in PMCs.