Feasibility and complications after transoral endoscopic thyroidectomy via vestibular approach (TOETVA) - a single-center first experience case series.

BACKGROUND: This paper reports on the first experience after implementation of a transoral endoscopic thyroidectomy via vestibular approach (TOETVA) as an alternative to (partial) thyroidectomy or isthmusectomy in a single center. Feasibility, implementation and specific complications are addressed. METHODS: All patients who underwent a TOETVA procedure in our center between November 2019 and March 2023 were included. The surgical technique was performed as described by Anuwong et al. All procedures were performed by two dedicated head- and neck surgeons. RESULTS: A total of 20 patients were included. All patients underwent TOETVA surgery as planned and no conversions were needed. Observed complications were post-operative wound infections (POWI) (2/20; 10%), clinically significant seroma (1/20, 5%) and unilateral hemiparesis of the larynx (3/20; 15%). Permanent mental nerve damage was seen in 3/20 patients (15%), and 4 other patients (20%) experienced transient neuropraxia. CONCLUSIONS: TOETVA is a feasible alternative to (partial) thyroidectomy or isthmusectomy in selected patients. Special care should be taken when placing the trocars in the oral vestibulum to prevent mental nerve damage. Experience and training are essential for implementing the TOETVA procedure. TRIAL REGISTRATION: This study was registered to ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: NCT05396703.

Accuracy and diagnostic performance of the Bethesda system for reporting thyroid cytopathology in a tertiary endocrine surgical referral center in Belgium.

BACKGROUND: The Bethesda System for Reporting Thyroid Cytopathology is a commonly used classification for fine needle aspiration (FNA) cytology of suspicious thyroid nodules. The risk of malignancy (ROM) for each category has recently been analyzed in three international databases. This paper compares the diagnostic performance of the Bethesda classification in a high-volume referral center in Belgium. METHODS: All consecutive thyroid procedures were registered in a prospective database from January 2010 till August 2022. Patient and surgical characteristics, preoperative Bethesda categories, and postoperative pathology results were analyzed. RESULTS: Out of 2219 consecutive thyroid procedures, 1226 patients underwent preoperative FNA. Papillary thyroid cancer was the most prevalent malignancy (N = 119, 70.4%), followed by follicular (N = 17, 10.1%) and medullary thyroid cancer (N = 15, 8.9%). Micropapillary thyroid cancer was incidentally found in 46 (3.8%) patients. Bethesda categories I, II, III, IV, V, and VI, respectively, represented 250 (20.4%; ROM 4.4%), 546 (44.5%; ROM 3.8%), 96 (7.8%; ROM 20.8%), 231 (18.8%; ROM 15.2%), 62 (5.1%; ROM 72.6%), and 41 (3.3%; ROM 90.2%) patients. Overall ROM was 13.8%. An negative predictive value (NPV) of 96.2% was found. Overall specificity was 64.2% with a positive predictive value (PPV) of 31.9%. Diagnostic accuracy was 67.8%. Compared to international databases (CESQIP, EUROCRINE, and UKRETS), ROM in this study appeared lower for Bethesda category IV (15.2 vs. 26.7% and p = 0.612). CONCLUSION: Despite being validated in numerous studies, ROM based on preoperative FNA cytology classified according to the Bethesda classification may vary among surgical centers and countries as this study reveals a higher NPV and lower PPV.

Diffuse large B-cell lymphoma presenting as an inguinal hernia - case report.

BACKGROUND: Diffuse large B-cell lymphoma (DLBCL) masquerading as a recurrent inguinal hernia is rare. We report the case of a 73-year-old male patient who presented with a symptomatic bulge in his left groin. Medical history revealed bilateral preperitoneal inguinal hernia repair, osteoporosis and atrial fibrillation. The patient's further history was not significant. METHODS: Sonography revealed recurrence of an indirect inguinal hernia (4.5 cm × 2.3 cm) on the left, with bilateral subcutaneous lymph nodes that were deemed unremarkable. We planned an elective left-sided anterior inguinal repair. Apixaban was stopped two days prior to surgery. RESULTS: During surgery we identified the bulge as a lump attached to the spermatic cord. No hernial sac was present. Together with the consulting urologist, we concluded a possible malignant etiology and performed an orchiectomy along with resection of the lump. CONCLUSION: Microscopic and immunohistochemical analysis revealed a DLBCL with non-germinal center phenotype and c-MYC rearrangement. Further staging confirmed stage IE disease with extranodal paratesticular involvement. The patient was subsequently treated with rituximab in combination with cyclophosphamide, doxorubicin, vincristine, prednisone and showed complete metabolic remission after two cycles. This case illustrates the broad differential diagnosis of inguinal swelling and (para)testicular tumors.