Indices of ACTH-stimulated adrenal venous sampling as predictors of postsurgical outcomes in primary aldosteronism.

OBJECTIVE: This study aimed to investigate the impact of indices of adrenal venous sampling (AVS) on postsurgical outcomes in patients with primary aldosteronism (PA). DESIGN AND PATIENTS: This retrospective study determined biochemical and clinical outcomes based on ACTH-stimulated AVS parameters (lateralisation index [LI], contralateral ratio [CLR], and ipsilateral ratio [ILR]) in 251 patients with PA at 3 months after surgery. RESULTS: Modified complete biochemical success was achieved in 8 of 12 (66.7%) patients with LI = 3-4, 39 of 47 (83.0%) with LI = 4-10, and 155 of 169 (91.7%) with LI ≥ 10 (p = .004 for trend). Modified complete biochemical success was achieved in 29 of 38 (76.3%) patients with CLR ≥ 1 and ILR ≤ 2, 73 of 86 (84.9%) with CLR = 0.25-1 and ILR > 2, and 100 of 104 (96.2%) with CLR < 0.25 and ILR > 2 (p = .001 for trend). After adjusting for confounders, modified complete biochemical success was associated with an LI ≥ 10 (odds ratio [OR] = 6.32; 95% confidence interval [CI] = 1.33-29.93) using LI = 3-4 as a reference and combined CLR < 0.25 and ILR > 2 (OR = 11.49; 95% confidence interval [CI] = 2.49-53.01) using combined CLR ≥ 1 and ILR ≤ 2 as a reference. Using combined CLR ≥ 1 and ILR ≤ 2 as a reference, complete clinical success was associated with combined CLR < 0.25 and ILR > 2 (OR = 3.10; 95% CI = 1.03-9.28) and combined CLR = 0.25-1 and ILR > 2 (OR = 4.92; 95% CI = 1.64-14.76). CONCLUSION: LI ≥ 10 may be appropriate for achieving biochemical success. With ILR > 2, CLR < 0.25, and CLR < 1 may be appropriate for achieving biochemical and clinical success, respectively.

The association between the type of anesthesia and hemodynamic instability during pheochromocytoma surgery: a retrospective cohort study.

BACKGROUND: Pheochromocytoma often carries a risk for perioperative hemodynamic instability (HDI). The aim of this study is to evaluate the risk factors of intraoperative HDI during minimally invasive posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma. MATERIALS AND METHODS: This retrospective study analyzed the prospectively collected data of 172 patients who underwent laparoscopic PRA or robotic PRA for pheochromocytoma between January 2014 and December 2020 at a single tertiary center. The patients were divided into two groups according to the intraoperative hypertensive event of systolic blood pressure (> 160 mmHg). The clinical manifestations and perioperative hemodynamic conditions were analysed. RESULTS: In the multivariate logistic regression analysis, the tumor size (> 3.4 cm) [OR 3.14, 95% confidence intervals (CI) (1.48-6.64), p = 0.003], type of preoperative alpha-blocker (selective type) [OR 3.9, 95% CI (1.52-10.02), p = 0.005], preoperative use of beta-blockers [OR 3.94, 95% CI (1.07-14.49), p = 0.039] and type of anesthesia [total intravenous anesthesia (TIVA) vs. balanced anesthesia (BA)] [OR 2.57, 95% CI (1.23-5.38), p = 0.012] were determined as independent risk factors of intraoperative hypertensive events during minimally invasive adrenalectomy. CONCLUSIONS: The type of anesthesia was independently associated with intraoperative HDI along with larger tumor size, type of preoperative alpha-blocker and the use of preoperative beta-blockers. TIVA increased the risk of intraoperative hypertensive events compared with BA. Thus, the consideration of the type of anesthesia prior to adrenal surgery for pheochromocytoma along with the use of preoperative non-selective alpha-blockers may be beneficial in minimizing the risk of intraoperative HDI.

Comparison Between Familial and Sporadic Non-medullary Thyroid Carcinoma: A Retrospective Individual Risk Factor-Matched Cohort Study.

BACKGROUND: This study aimed to compare clinicopathologic features and outcomes between patients with familial non-medullary thyroid carcinoma (FNMTC) and patients with sporadic non-medullary thyroid carcinoma (SNMTC) after performing individual risk factor-matching. Additionally, the study evaluated a dynamic risk stratification (DRS) system to validate its usefulness for familial-type thyroid carcinoma. METHODS: After individual risk factor-matching, 286 patients remained in the FNMTC group, and 858 patients were assigned to the SNMTC group consisting of papillary thyroid carcinoma (PTC). The prognostic outcomes were compared between the two groups in a matched cohort. RESULTS: During the mean follow-up period of 142 months, recurrences were experienced by 64 patients in the sporadic group (7.5%) and 29 patients in the familial group (10.1%). In the multivariate analysis, the independent risk factors for recurrence were primary tumor size (p = 0.033), gross extrathyroidal extension (p = 0.001), and lymph node metastasis (p < 0.001). The independent risk factors did not include family history alone (p = 1.101) or the number of affected family members (p = 0.122 for 2 members and p = 0.625 for ≥ 3 members). In this matched-cohort study, the DRS system was well adjusted in the FNMTC and SNMTC groups. Moreover, the proportion of DRS categories and the recurrence rate in each DRS category were similar between the familial and sporadic groups. CONCLUSIONS: Family history did not present a statistically significant association with a poor prognosis for PTC patients. With a family history of PTC alone, less aggressive treatment could be considered. In this matched cohort, DRS was adjusted well and could be useful in predicting prognosis, even for PTC patients with a family history of PTC.

Modified risk stratification based on cervical lymph node metastases following lobectomy for papillary thyroid carcinoma.

OBJECTIVE: Evidence for American Thyroid Association (ATA) risk stratification stems largely from studies involving patients undergoing total thyroidectomy. We aimed to assess the risk of recurrence according to the present ATA risk stratification system in patients who underwent lobectomy. DESIGN: Retrospective cohort study. PATIENTS: Patients who underwent thyroid lobectomy for 1-4 cm-sized papillary thyroid carcinoma (n = 571). MEASUREMENTS: Disease-free survival (DFS) was compared according to the ATA risk stratification, and specific lymph node (LN) characteristics were evaluated to modify the ATA criteria with a higher predictability for recurrence. RESULTS: Based on the ATA risk stratification, 439 patients (61.1%) were classified into intermediate- or high-risk group, and consideration for completion thyroidectomy is suggested by ATA guidelines for these patients. However, no significant differences were found in DFS among the low-, intermediate- and high-risk groups (P = .9). In contrast, when patients were stratified according solely to the LN criteria from the ATA risk stratification, only 127 patients (22.2%) had intermediate risk (intermediate-N1a) and exhibited significantly poorer DFS than those with N0 disease (P = .035). Modifying the intermediate-N1a criteria by adding the extranodal extension (ENE) status and omitting the clinical nodal disease enabled the subclassification of 19 patients (3%) with a high risk for recurrence. CONCLUSIONS: The present study suggests that risk stratification based solely on LN metastases is more reasonable for predicting structural persistence/recurrence following lobectomy than that based on the overall ATA criteria. Considering the ENE status can assist in selecting patients with a high risk of recurrence to minimize further treatments.

Safety and feasibility of reduced-port site surgery for robotic posterior retroperitoneal adrenalectomy.

BACKGROUND: Minimally invasive surgery, such as laparoscopic adrenalectomy and robotic adrenalectomy, has become a treatment of choice for benign adrenal tumors. Efforts are ongoing to minimize the invasiveness of the procedure and to reduce the number of port sites. The primary endpoint of this study was the safety and feasibility of a reduced-port site technique for robotic posterior retroperitoneal adrenalectomy (RPRA). METHODS: This study retrospectively analyzed 74 RPRAs performed by a single surgeon, including 30 conventional three-port site early-phase RPRAs, 30 three-port site late-phase RPRAs, and 14 reduced-port site RPRAs. Reduced-port site RRPA was defined as using two port sites: one for a multi-glove port and one for an additional side port. The clinicopathological features and surgical outcomes were compared in these three groups. RESULTS: No major complications were observed following RPRA in the three groups of patients. Operation time, pain score, and hospital stay did not differ significantly among these three groups. CONCLUSIONS: RPRA using a reduced-port site system was safe and feasible and may be a good alternative to conventional three-port site RPRA for benign adrenal tumors in certain situations.

The value of preoperative antithyroidperoxidase antibody as a novel predictor of recurrence in papillary thyroid carcinoma.

The link between chronic lymphocytic thyroiditis (CLT) and papillary thyroid carcinoma (PTC) is widely recognized. Considering the strong association between raised antithyroidperoxidase antibody (TPOAb) and CLT, we postulated that the preoperative TPOAb can predict the prognosis of PTC, particularly for recurrence. A total of 2,070 patients who underwent total thyroidectomy for classical type PTC with tumor size ≥1 cm and with available data on preoperative TPOAb and TgAb were enrolled to compare disease-free survival (DFS) according to the presence of preoperative TPOAb, TgAb, and coexistent CLT. Patients with positive preoperative TPOAb had a significantly better DFS compared to patients without positive preoperative TPOAb (hazard ratio (HR) 0.53; 95% confidence interval (CI) 0.30-0.94, p = 0.028) while no difference in DFS was found according to preoperative TgAb status. Positive preoperative TPOAb was an independent prognostic factor for structural persistent/recurrent disease after adjustment for major preoperative risk factors such as age, sex, and tumor size (HR 0.52, 95% CI 0.28-0.99, p = 0.048). Although the coexistence of CLT lowered the risk for structural persistence/recurrence in univariate analysis (HR 0.52, 95% CI 0.31-0.86, p = 0.012), it was not an independent favorable prognostic factor by multivariate analysis (HR 0.65, 95% CI 0.38-1.10, p = 0.106). However, when coexistent CLT was combined with positive preoperative TPOAb, it indicated an independent protective role in structural persistent/recurrent disease (HR 0.39, 95% CI 0.16-0.98, p = 0.045). Our study clearly showed that presence of preoperative TPOAb can be a novel prognostic factor in predicting structural persistence/recurrence of PTC.

Clinical Significance of Gross Invasion of Strap Muscles in Patients With 1- to 4-cm-Sized Papillary Thyroid Carcinoma Undergoing Lobectomy.

BACKGROUND: Given the emerging evidence supporting the lack of prognostic significance of gross extrathyroidal extension invading only strap muscles (strap-gETE), this study investigated whether lobectomy is feasible for patients with strap-gETE. METHODS: A retrospective cohort study was conducted with 636 patients who had 1- to 4-cm-sized papillary thyroid carcinoma (PTC) treated with thyroid lobectomy. Patients with gross invasion of perithyroidal organs other than strap muscles or synchronous distant metastasis were excluded from the study. Disease-free survival (DFS) was compared according to the presence of strap-gETE. RESULTS: Strap-gETE was present in 50 patients (7.9%), with the remaining 586 patients (92.1%) showing no evidence of gETE. During the median follow-up period of 7.4 years, 6% of the patients with strap-gETE and 5.1% of the patients without gETE experienced structural persistent/recurrent disease (p = 0.99). No differences in DFS were observed between the two groups (hazard ratio [HR], 1.24; 95% confidence interval [CI], 0.38-4.08; p = 0.720). After adjustment for five major risk factors (age, gender, tumor size, multifocality, and cervical lymph node metastasis status) in the multivariate analysis, the presence of strap-gETE did not exhibit an independent role in the development of structural persistent/recurrent disease (HR 1.05; 95% CI 0.24-4.53, p = 0.950). CONCLUSIONS: Strap-gETE did not increase the risk of structural persistent/recurrent disease for the patients who underwent lobectomy for 1- to 4-cm-sized PTC. The study data support the limited role of strap-gETE in clinical outcomes and may broaden the indications for lobectomy for patients with PTCs.

Dynamic risk stratification system in post-lobectomy low-risk and intermediate-risk papillary thyroid carcinoma patients.

OBJECTIVE: The dynamic risk stratification (DRS) and its current definition of each response-to-therapy category in post-lobectomy papillary thyroid carcinoma (PTC) patients have not been well studied. This study aimed to validate the DRS system and to investigate useful thyroglobulin (Tg) or anti-Tg antibody (Ab)-related parameters in defining each response-to-therapy category. DESIGN: Retrospective observational study. PATIENTS: This historical cohort study included 619 patients with PTC treated by thyroid lobectomy. MEASUREMENTS: All enrolled participants were stratified according to the American Thyroid Association (ATA) initial risk stratification system and DRS system, respectively. The association between these stratifications and structural recurrence was evaluated. RESULTS: The median follow-up period was 103 months. Structural recurrence occurred in 1.6% of the patients with excellent response, 3.8% of those with indeterminate response, 2.9% of those with biochemical incomplete response, and all patients with structural incomplete response. Five (1.5%) of the low-risk patients and 14 (5.0%) of the intermediate-risk patients had structural recurrence. The disease-free survival curves showed significant differences according to the DRS (P < .001) and ATA initial risk stratification (P = .012), respectively. The proportion of variance explained the DRS system and ATA risk stratification system for structural recurrence was 32.4% and 29.4%, respectively. A thyroid-stimulating hormone (TSH) level >2.75 µU/mL at 1 year after the initial operation (P < .001) was the only valuable risk factor for structural recurrence identified in this study. CONCLUSION: The long-term postoperative management of PTC patients treated with thyroid lobectomy could be guided based on the DRS.

The prognostic value of serum thyroid-stimulating hormone level post-lobectomy in low- and intermediate-risk papillary thyroid carcinoma.

BACKGROUND: This study was undertaken to determine the optimal thyroid-stimulating hormone (TSH) value associated with structural recurrence in patients with low-risk or intermediate-risk papillary thyroid carcinoma (PTC) who underwent thyroid lobectomy. METHODS: Patients with PTC (n = 1047) who received thyroid lobectomy and central compartment node dissection were included in the study. RESULTS: Structural recurrence occurred in 42 of the patients (4.0%), and no patient died of PTC. Multivariate analysis showed a primary tumor size (with a cut-off of 0.85 cm) and serum TSH level measured 1 year after the initial surgery (cut-off 1.85 mU/L) independently predicted structural recurrence. CONCLUSIONS: TSH levels during the early postoperative period need to be monitored and maintained in the lower normal range even in patients with low- or intermediate-risk PTC undergoing thyroid lobectomy.

Dynamic risk stratification in papillary thyroid carcinoma measuring 1 to 4 cm.

BACKGROUND AND OBJECTIVES: This study aimed to validate the dynamic risk stratification (DRS) system, evaluate its correlation with structural recurrence, and assess the clinicopathological risk factors associated with a nonexcellent response to initial therapy in patients with papillary thyroid cancer (PTC) measuring 1 to 4 cm. METHODS: A total of 762 patients with classic PTC measuring 1 to 4 cm were classified into four categories based on their response to initial therapy 2 years postoperatively. RESULTS: Structural recurrent disease occurred in 4.7%, 17.1%, 48.4%, and 83.9% of patients with excellent, indeterminate, biochemically incomplete, and structurally incomplete responses, respectively, at the time of the last follow-up. The response to initial therapy in the DRS was one of the independent risk factors for structural recurrence. The disease-free survival curves of patients with different responses showed significant differences (P < 0.001). Extensive extrathyroidal extension, lymph node (LN) metastasis, number of metastatic LNs greater than 2.0, metastatic LN ratio greater than 0.22, and extranodal extension were independent risk factors for nonexcellent response to initial therapy. CONCLUSIONS: DRS can be a useful tool in predicting structural recurrence and guiding postoperative management and follow-up strategies in patients with PTC measuring 1 to 4 cm.

Is Male Gender a Prognostic Factor for Papillary Thyroid Microcarcinoma?

BACKGROUND: Male gender is a prognostic factor of poor outcome in papillary thyroid carcinoma (PTC). We investigated the prognostic role of male gender in papillary thyroid microcarcinoma (PTMC). METHODS: We included 2930 patients who underwent surgery at Asan Medical Center for PTC. Clinicopathologic characteristics from the patients' medical records were compared for male and female PTC patients. Independent prognostic factors for recurrence in PTC and PTMC were evaluated after propensity score matching analysis. The median follow-up period was 82 months. RESULTS: Recurrence and death were more common in male patients with PTC than in female patients with PTC (12.6 vs. 9.6%, p = 0.03 and 2.2 vs. 0.6%, p < 0.001, respectively). However, there was no difference in disease-free survival between male and female PTMC patients (p = 0.57). Multivariate analysis after propensity score matching revealed that male gender is not an independent prognostic factor of recurrence in PTMC (hazard ratio [HR] 1.5, 95% confidence interval 0.75-5.33, p = 0.17), but that it is an independent prognostic factor in PTC >1 cm (HR = 3.06, 95% confidence interval 1.34-6.98, p = 0.008). CONCLUSIONS: Male gender is an independent prognostic factor for recurrence in PTC >1 cm, but it is not a prognostic factor in PTMC.

Lack of Efficacy of Radioiodine Remnant Ablation for Papillary Thyroid Microcarcinoma: Verification Using Inverse Probability of Treatment Weighting.

BACKGROUND: Most of the increase in thyroid cancer in recent decades has been due to papillary thyroid microcarcinoma (PTMC). We evaluated the efficacy of radioiodine remnant ablation (RRA) in patients with PTMC. METHODS: This historical cohort study included 1932 PTMC patients without lateral cervical lymph node (LN) or distant metastasis who underwent total thyroidectomy (TT) during the median 8.3 years of follow-up. The clinical outcomes of patients with or without RRA were compared using weighted logistic regression models with the inverse probability of treatment weighting (IPTW) method and considering risk factors, including age, sex, primary tumor size, extrathyroidal extension, multifocality, and central cervical LN metastasis. RESULTS: The median primary tumor size of the RRA group was significantly larger than that of the no-RRA group (0.7 vs. 0.5 cm, P < 0.001). There were significantly more patients with multifocality, extrathyroidal extension, and cervical LN metastasis in the RRA group compared with the no-RRA group. There was no significant difference in recurrence-free survival between the two groups (P = 0.11). Cox proportional-hazard analysis with IPTW by adjusting for clinicopathological risk factors demonstrated no significant difference in recurrence of PTMC according to RRA treatment (hazard ratio [HR] 2.02; 95% confidence interval [CI] 0.65-6.25; P = 0.2). CONCLUSIONS: RRA had no therapeutic effect on the clinical outcomes of patients with PTMC who underwent TT. Surgical treatment without RRA could be applicable for patients with PTMC if there is no evidence of lateral cervical LN metastasis or distant metastasis.

Features of papillary thyroid microcarcinoma associated with lateral cervical lymph node metastasis.

OBJECTIVES: Papillary thyroid microcarcinoma (PTMC) has an excellent prognosis with an indolent disease course. However, some PTMCs have an aggressive course with lateral cervical lymph node (LCLN) metastasis or distant metastasis. This study aimed to evaluate the pre-operative features of PTMC associated with LCLN metastasis. DESIGN AND PATIENTS: This retrospective cohort study with a nested, matched case-control design included 199 PTMC patients with LCLN metastasis at initial surgery (N1b group) and 196 PTMC patients without any LN metastasis or persistent disease (N0 NED group) as controls; primary tumour sizes were matched. RESULTS: Compared with the N0 NED group, the N1b group was younger (<50 years) and more likely to be male (P = 0·002 and P = 0·003, respectively). On pre-operative neck ultrasonography (US), N1b group PTMCs were more commonly associated with a location in the upper lobes of the thyroid, or in the subcapsular area and microcalcifications than N0 NED group PTMCs (all P < 0·001). An increase in the number of these features was significantly associated with a higher risk of LCLN metastasis (P < 0·001). Evaluation of the clinical and pre-operative US characteristics of 26 patients with confirmed LCLN recurrence after initial treatment of clinical N0 PTMCs revealed that the distribution of the number of suspicious features in these patients was similar to that of the N1b group. CONCLUSIONS: Papillary thyroid microcarcinomas in young (<50 years) or male patients, with an upper lobe or subcapsular location, and with microcalcification have a higher risk of LCLN metastasis. Individualized management according to the number of these suspicious features may be needed for small thyroid nodules.

Preoperative clinicopathological characteristics of patients with solitary encapsulated follicular variants of papillary thyroid carcinomas.

BACKGROUND AND OBJECTIVES: Clinical outcomes in patients with the follicular variant of papillary thyroid carcinoma (FVPTC) tend to vary according to the pathological subtypes. We aimed to evaluate the clinicopathological characteristics including preoperative radiological and cytopathological diagnoses in patients with solitary encapsulated FVPTCs (EFVPTCs) to prove the preoperative assessment dilemma. METHODS: Patients with solitary FVPTCs who underwent thyroid surgery were included. RESULTS: Of 271 patients, 194 patients (72%) had EFVPTCs, whereas 77 patients (28%) had infiltrative FVPTCs (IFVPTCs). EFVPTCs had larger tumor sizes (P < 0.001) and lower frequencies of extrathyroidal extension (P < 0.001) and cervical lymph node (LN) metastasis (P < 0.001) than IFVPTCs. There were significant differences in ultrasonography (US) findings, preoperative cytopathological diagnosis, and the prevalence of BRAF mutations between EFVPTCs and IFVPTCs. Invasive EFVPTCs were diagnosed in 89 patients (33%) and non-invasive EFVPTCs in 105 patients (39%). Non-invasive subtype had smaller tumor sizes (P = 0.001) and lower frequencies of vascular invasion (P = 0.04) and cervical LN metastasis (P = 0.02). There were no significant differences in preoperative US findings and cytopathological diagnoses between invasive and non-invasive EFVPTCs. CONCLUSIONS: Clinicopathological characteristics of EFVPTCs, including preoperative US findings, are different from those of IFVPTCs. However, preoperative radiological and cytopathological findings could not distinguish non-invasive and invasive EFVPTCs.

Prognostic Impact of Further Treatments on Distant Metastasis in Patients With Minimally Invasive Follicular Thyroid Carcinoma: Verification Using Inverse Probability of Treatment Weighting.

BACKGROUND: The aim of this study was to evaluate the prognostic impact of further treatments in minimally invasive follicular thyroid carcinoma (MIFTC) patients. METHODS: The risk factors for distant metastases were analyzed, and the impact of surgical extent on distant metastasis was verified by using weighted logistic regression models with inverse-probability of treatment weighting (IPTW). RESULTS: 166 patients including 31 males (18.7 %) and 135 females (81.3 %), with the mean age of 41.5 ± 13.5 years, were enrolled for this study. The median follow-up period was 103.5 months (range, 13-244 months). Seven patients (4.2 %) had distant metastases during follow-up period. The presence of vascular invasion (Hazard ratio [HR] = 29.06; 95 % Confidence Interval [CI] = 3.06-209.08; p = 0.015) and extensive vascular invasion ≥4 foci (HR = 40.57; 95 % CI = 2.09-789.13; p = 0.014) were the independent risk factors for distant metastasis by multivariate analysis. Surgical extent did not influence distant metastasis. Logistic regression with IPTW also demonstrated that there were no statistically significant differences in the development of distant metastasis based on surgical extent (HR = 1.28; 95 % CI = 0.15-10.87; p = 0.823). CONCLUSIONS: The presence of extensive vascular invasion is the most powerful predictor of distant metastasis. However, it is noteworthy that further treatments do not demonstrate an advantageous effect on preventing distant metastasis during the follow-up period.

Core needle biopsy could reduce diagnostic surgery in patients with anaplastic thyroid cancer or thyroid lymphoma.

OBJECTIVE: To evaluate the diagnostic performance of fine needle aspiration (FNA) and core needle biopsy (CNB) in patients with anaplastic thyroid cancer (ATC) or thyroid lymphoma (TL). METHODS: Between January 2000 and March 2012, 104 patients were diagnosed with ATC or TL by means of ultrasound (US)-guided FNA, CNB, or surgery. This study ultimately included 99 patients with ATC (n = 59) or TL (n = 40). We evaluated the sensitivity and positive predictive value of FNA and CNB for the diagnosis of ATC and TL, and compared the rates of diagnostic surgery between FNA and CNB. RESULTS: FNA was used in 83 patients, and CNB was used in 32 patients initially (n = 16), after FNA results (n = 8), or simultaneously with FNA (n = 8). CNB achieved sensitivity of 87.5 % (28/32) and positive predictive value of 100.0 % (28/28) for the diagnosis of ATC and TL. The respective values for FNA were 50.6 % (40/79) and 90.9 % (40/44). The rate of diagnostic surgery was significantly lower after CNB (4/32, 12.5 %) than after FNA (28/79, 35.4 %) (p = 0.020). CONCLUSIONS: CNB was able to reduce unnecessary diagnostic surgery in patients with ATC or TL by virtue of its superior diagnostic sensitivity and positive predictive value compared to FNA. KEY POINTS: • Diagnostic sensitivity and PPV for CNB were 87.5 % and 100.0 %, respectively. • The respective values for FNA were 50.6 % and 91.0 % for ATC and TL. • Diagnostic surgery rates were reduced after CNB compared to FNA (p = 0.020).

Changing trends in the clinicopathological features and clinical outcomes of medullary thyroid carcinoma.

BACKGROUND: The early detection of papillary thyroid cancer has contributed to the increase in the incidence and improved clinical outcomes. However, recent changes of medullary thyroid carcinoma (MTC) over time remain unclear. We evaluated changes of the clinicopathological characteristics and clinical outcomes in patients with MTC in recent years. METHODS: A total of 109 MTC patients were classified based on the year of initial surgery: 1996-2000 (n = 14), 2001-2006 (n = 39), and 2007-2011 (n = 56). RESULTS: The primary tumor size significantly decreased and the proportion of microMTCs (size ≤1 cm) increased over time (P = 0.002 and P < 0.001, respectively). The proportion of patients with cervical lymph node (LN) metastasis significantly decreased (P = 0.037), and the ratio of metastatic LNs significantly decreased (P = 0.011). Disease-free survival (DFS) rate of patients was significantly improved over time (P = 0.007). There was no significant difference in DFS between microMTC and macroMTC patients. However, more advanced LN stage patients demonstrated more recurrences (P < 0.001). Especially, there were significantly more recurrences in patients with N1b diseases in comparison with patients without cervical LN metastases (P < 0.001). CONCLUSIONS: The prognosis of MTC patients has significantly improved in recent years. These changes could be associated with the early diagnosis before development of lateral and extensive cervical LN metastases. J. Surg. Oncol. 2016;113:152-158. © 2015 Wiley Periodicals, Inc.

Prognostic Value of the Number of Retrieved Lymph Nodes in Pathological Nx or N0 Classical Papillary Thyroid Carcinoma.

BACKGROUND: This study evaluated the clinical implications of the number of retrieved central lymph nodes (LN) for the recurrence and recurrence-free survival (RFS) outcomes in patients with pathological Nx (pNx) or N0 classical papillary thyroid carcinoma (PTC). METHODS: In total, 464 patients were enrolled following total thyroidectomy with central LN dissection. The risk factors related to recurrence and RFS were evaluated and compared between these groups. RESULTS: Age, primary tumor size, and number of retrieved central LNs were independent risk factors for recurrence according to multivariate analysis (p < 0.05). The cut-off value for the number of retrieved central LNs related to recurrence was 4.5. Group 2 (pN0; ≥5 nodes) demonstrated a significantly higher proportion of patients with an ablation-stimulated thyroglobulin (sTg) level <2.0 ng/mL (84.9 vs 61.1 %; p < 0.050) and control sTg level <1.0 ng/mL (92.1 vs 79.6 %; p < 0.050) in comparison with patients in group 1 (pNx or pN0; 1-4 nodes). Perioperative complication rates were comparable between groups. CONCLUSION: The number of retrieved central LNs is an independent risk factor for recurrence, even among patients with pNx or pN0 classical PTC. A thorough central LN dissection may therefore improve the long-term RFS rate.

Importance of the intraoperative appearance of preserved parathyroid glands after total thyroidectomy.

PURPOSE: Hypocalcemia after total thyroidectomy is a concern for every endocrine surgeon. We conducted this study to establish the value of the macroscopic appearance of preserved parathyroid glands after thyroidectomy in predicting post-thyroidectomy hypocalcemia. METHODS: In 2009, 237 patients underwent total thyroidectomy at our hospital. The macroscopic appearance of the preserved parathyroid glands was recorded and the serum calcium and intact parathyroid hormone levels were measured postoperatively. RESULTS: Thirteen patients (5.5 %) had transient hypocalcemia and 1 patient (0.4 %) had permanent hypocalcemia. All of the hypocalcemia patients with more than one normal preserved parathyroid had asymptomatic transient hypocalcemia that did not require medication. The sensitivity, specificity, positive predictive value, and negative predictive value for hypocalcemia with at least 1 normal preserved parathyroid were 78.6, 79.4, 19.3, and 98.3 %, respectively. CONCLUSION: The macroscopic appearance of preserved parathyroid glands and the number of well-preserved parathyroid glands after thyroidectomy proved effective in predicting post-thyroidectomy hypocalcemia.

Clinicopathological Significance of Minimal Extrathyroid Extension in Solitary Papillary Thyroid Carcinomas.

BACKGROUND: The definitive diagnosis of minimal extrathyroid extension (ETE) is subjective because a well-defined true capsule is absent in the thyroid gland. We subclassified the extent of minimal ETE and investigated the clinicopathological significance of the presence of minimal ETE in patients with solitary papillary thyroid carcinomas (PTCs) and solitary papillary thyroid microcarcinomas (PTMCs). METHODS: A series of 546 patients with solitary PTCs, including 144 patients with solitary PTMCs, were retrospectively analyzed. Whether the presence of minimal ETE had an effect on recurrence-free survival (RFS) along with other clinicopathological parameters was investigated. RESULTS: The only independent prognostic factor found to be associated with recurrence was the presence of LN metastasis in solitary PTC (p = 0.002) but not in solitary PTMC groups (p = 0.073). The presence of minimal ETE had no effect on RFS in both solitary PTC (p = 0.053) and solitary PTMC (p = 0.816). CONCLUSIONS: The presence of minimal ETE has no significant influence on RFS in solitary PTC and PTMC. There is a risk of overrepresenting the T3 category in solitary PTC and PTMC patients with minimal ETE.