Total vs hemithyroidectomy for intermediate risk papillary thyroid cancer: A 23 year retrospective study in a tertiary center.

BACKGROUND: There is much debate in the literature over the extent of surgery for patients with intermediate risk papillary thyroid cancer. We herein report our results in a local tertiary hospital. METHOD: We identify from our database patients with papillary thyroid cancer who underwent surgery in our hospital and were stratified to be of intermediate risk from the GAMES stratification system. Patients' demographic data, surgical and pathological details were recorded. Primary end points were disease specific survival (DSS) and recurrence free survival (RFS). RESULTS: From January 1993 to December 2016, 231 patients with papillary thyroid cancer underwent surgery of which 137 (59%) were of intermediate risk. 45 (33%) patients had hemithyroidectomy and 92 (67%) patients had total thyroidectomy. In the total thyroidectomy group, patients had a higher tumor (T) (p value = 0.009) and nodal (N) staging (p value = 0.001). They were also predicted to have a higher risk of recurrence according to the American Thyroid Association (ATA) classification (p value = 0.005). The 5 year DSS in both groups were 100%. The 5 year RFS in the total thyroidectomy and hemithyroidectomy groups were 92% and 100% respectively and were significantly different by the log rank test (p value = 0.02). The median follow up time was 54 months (range 4-276 months). CONCLUSION: The 5 year survival in intermediate risk papillary thyroid cancer is favorable. Hemithyroidectomy is an acceptable choice of operation in intermediate risk patients with a better risk profile.

Partial parotidectomy under local anesthesia for benign parotid tumors - An experience of 50 cases.

PURPOSE: Benign parotid tumors are adequately treated with partial parotidectomy, which is often performed under general anesthesia (GA). We have reported our preliminary results on the feasibility to perform parotidectomy under local anesthesia (LA). We hereby present our accumulated experience of partial parotidectomy under LA to further consolidate its feasibility, efficacy and safety in a larger series. MATERIALS AND METHODS: Case series review was carried out using our own center patients' database. 50 patients with parotid tumors were treated with partial parotidectomy under LA, using a retrograde nerve dissection approach from January 2006 to October 2016. The inclusion criteria encompassed mobile parotid nodules primarily operated after non-suspicious fine-needle aspiration cytology. Their demographics, complications and outcomes were evaluated. RESULTS: No procedure required conversion to GA. There were 48 benign tumors and 2 lymphomas based on the histopathologic examination. The commonest pathologies were pleomorphic adenoma (40%), Warthin's tumor (38%) and cyst (8%). The mean tumor size was 2.68 ±â€¯1.5 cm and the mean operative time was 91.5 ±â€¯34.7 min. Forty-two operations were done as day cases. Ten (20%) patients suffered from transient ear lobe numbness and two (4%) patients had sialocele. Transient facial palsy occurred in 2(4%) patients while another patient (2%) had persistent House-Brackmann grade II facial palsy. No tumor recurrence was noted during follow-up period. CONCLUSIONS: Partial parotidectomy adopting a retrograde nerve dissection under LA is feasible and minimally invasive in treating benign parotid tumors. It can avoid the adverse effects of general anesthesia and promote day surgery or minimize hospital stay.

Reconstruction with submental flap for aggressive orofacial cancer- an updated series.

PURPOSE: Submental flap is gaining popularity for head and neck reconstruction. We have reported in 2007 our early experience of using submental flap for aggressive orofacial malignancy. Novel flap design and application is described in this updated series. MATERIALS AND METHODS: 15 patients who had received submental flap reconstruction after extirpation of newly diagnosed aggressive orofacial lesions were retrieved. The details of the flap harvest was studied for flap size, inclusion of mylohyoid muscle, antegrade versus retrograde blood supply, and compared with our previous series. RESULTS: The dimension of flap skin paddle was 30cm2 (range 20-72). Retrograde pedicle flow was used in 2(13.3%) patients. Mylohyoid muscle was included in the flap in 6(40%) patients. There was no total flap necrosis while partial flap necrosis occurred in 1 patient(6.7%). There was a significant increase of inclusion of mylohyoid muscle to the flap in this series (p = 0.02). Novel techniques including double-paddled flap skin to resurface full-thickness defect and chimeric osteocutaneous mandible submental flap for maxillary defect were successfully performed. CONCLUSIONS: Submental flap is a viable reconstructive option in selected patients with aggressive orofacial malignancy. The indications are expanding and its technical modification is evolving and resulting in more innovative applications.

Prognostic value of lymph node density in buccal squamous cell carcinoma.

PURPOSE: Lymph node density(LND) has been shown to be a better prognosticator than conventional nodal classification to predict prognosis for squamous cell carcinoma(SCC) of the oral cavity. However, studies focusing on subsites of oral cancer are meager. The role of LND for buccal SCC was evaluated in this study. METHODS: A total of 39 patients with buccal SCC primarily treated surgically with neck dissection were identified. LND was defined as the number of positive nodes over the number of nodal yield. The cut-off of LND was ≤0.07 or >0.07. Patient demographic data and clincopathologic parameters were described. Survival was expressed by Kaplan-Meier method and correlation with survival is analyzed with log-rank test. IBM SPSS Statistics version 22 was used for data computation. RESULTS: The median follow-up was 79.0months and median nodes removed was 23 (range 8-93). Positive nodal involvement was found in 19(48.7%) patients. The 5-year and 10-year OS were 67.4% and 42.5% whilst for DSS were 69.2% and 65.5%, respectively. When pT-, pN-, LND-classification and AJCC stage were analyzed for the whole series, only pN- (p=0.006) and LND-classification (p=0.002) were significant factors for OS, while pT-, pN-, LND-classification and AJCC stage were all significant factors for DSS. When only cases with positive nodal spread were considered, the pN-classification (pN1 vs pN2) was not a significant risk factor for either OS (p=0.075, HR 3.10(CI 0.89-10.76)) and DSS (p=0.074, HR 3.58(CI 0.88-14.56)). By contrast, LND-classification (≤0.07 vs >0.07) remained a significant predictor for OS (p=0.03, HR 3.95(CI 1.15-13.63)), but not for the DSS (p=0.112, HR 2.92(CI 0.78-10.99)). CONCLUSION: The prognostic value of LND on buccal SCC is supported in this study. The results also suggest that LND is better than the conventional pN-classification to predict OS. Further studies on LND with big sample size for buccal SCC or other subsites of OSCC are worthwhile.

The role of human papillomavirus in head and neck squamous cell carcinoma: A case control study on a southern Chinese population.

HPV plays a role in the development of a portion of head and neck squamous cell carcinoma (HNSCC), but only limited information on its role in southern Chinese population is available. A multicenter case-control study was conducted. HPV type, viral integration, E6/7 mRNA expression status, and TP53 mutation were determined. A total of 228 HNSCC were recruited including 137 (60.1%) oral SCC, 34 (14.9%) oropharyngeal SCC, 31 (13.6%) laryngeal SCC, 21 (9.2%) hypopharyngeal SCC, and 5 (2.2%) lip and paranasal sinus SCC. High-risk HPV infection was found in 7.5% (17/228) of HNSCC, but only a small proportion of samples had evidence of viral integration (5.3%, 12/228) or E6/7 mRNA expression (4.4%, 10/228). HPV infection with oncogenic phenotype (integration and E6/7 mRNA expression) was significantly more common in oropharyngeal SCC than controls (9/34, 26.5% vs. 0/42, 0.0%, P < 0.001). Smoking showed a significant association with HNSCC, oropharyngeal SCC, and laryngeal SCC. TP53 mutation was associated with HNSCC (P < 0.001). Older age, TP53 mutation, and HPV16 infection with oncogenic phenotypes were independently associated factors for HNSCC with odds ratios of 1.03 (1.02-1.05), 3.38 (1.71-6.66), and 9.19 (1.13-74.68), respectively. High-risk HPV infection of head and neck mucosa is not uncommon in the Hong Kong population. This study found that 26-30% of oropharyngeal carcinoma was associated with HPV infection, mostly HPV16, and that smoking which predisposes to TP53 mutations was another important risk factor.

Postoperative PTH monitoring of hypocalcemia expedites discharge after thyroidectomy.

PURPOSE: Hypocalcemia is the most common complication after total thyroidectomy. Some patients need to stay in the hospital for monitoring of hypocalcemic symptoms and serum calcium levels for several days. We investigated the efficacy and safety of using early postoperative parathyroid hormone (PTH) results for early discharge after thyroidectomy. MATERIALS AND METHODS: A retrospective cohort study of 2 sequential groups of patients undergoing total thyroidectomy between January 2010 and March 2013 was undertaken. Patients were divided into 2 groups. In Group 1 (before June 2011), patients had daily monitoring of serum calcium level and hypocalcemic symptoms. They were discharged when calcium level was static and asymptomatic. Postoperative PTH was not utilized for discharge plan. In Group 2 (after June 2011), postoperative PTH and calcium level on day 1 were utilized to dictate subsequent management and discharge plan. RESULTS: Of the 107 patients reviewed, 54 (50.5%) were in Group 1 and 53 (49.5%) were in Group 2. A total of 51 (47.7%) patients developed hypocalcemia. The two groups were comparable in demographic data, early postoperative PTH value, rate of hypocalcemia, the need for oral calcium and vitamin D supplements and rate of permanent hypoparathyroidism. Fewer patients in Group 2 experienced hypocalcemic symptoms, p=0.005. None of the patients in Group 2 needed intravenous calcium supplement (p=0.003). The median postoperative hospital stay for Group 1 was 4 days and for Group 2 was 1 day (p<0.0001). CONCLUSIONS: Postoperative PTH level after total thyroidectomy facilitates early supplementation therapy and abates symptomatic hypocalcemia. It also allows early and safe patient discharge.

Parotidectomy under local anesthesia--report of 7 cases.

OBJECTIVE: Parotidectomy is usually carried out under general anesthesia. We reported our early experience of performing parotidectomy under local anesthesia. STUDY DESIGN: Case series reviewed. SETTING: Head and neck services of a regional hospital. PATIENTS, INTERVENTION, AND RESULTS: Seven patients underwent parotidectomy under local anesthesia. The indications were high risk for general anesthesia due to co-morbidity in 2 patients and personal preference for the rest. The operations were performed by retrograde facial nerve dissection after superficial cervical plexus block and incision wound infiltration with local anesthetics. There was no conversion to general anesthesia. Six operations were carried out in the setting of ambulatory procedure and were discharged on the same day. Transient mild facial paresis occurred in 2 patients. CONCLUSION: Parotidectomy under local anesthesia can be conducted successfully and avoid the adverse effect of general anesthesia.

Submandibular sialoadenectomy with local anesthesia in the era of minimally invasive surgery.

OBJECTIVE: To assess the feasibility and advantages of submandibular sialoadenectomy under local anesthesia. STUDY DESIGN: Retrospective clinical study. SUBJECTS AND METHODS: Twenty patients with benign submandibular masses underwent submandibular sialoadenectomy. The procedure was carried out under local anesthesia (LA) in 12 patients and general anesthesia (GA) in 8 patients. The patient and tumor characteristics, as well as treatment outcome or complications, were compared between the two groups. RESULTS: There was no conversion from LA to GA. Nine patients in the LA group could be discharged as day-case surgery versus none in the GA group, P = 0.001. The postoperative hospital stay was also much shorter in the LA group: 0.4 day vs 2.0 days, P < 0.001. Postoperative vomiting occurred in only two of the eight patients of the GA group. Complication rate was similar. CONCLUSION: Submandibular sialoadenectomy under local anesthesia is feasible. It can shorten the hospital stay and facilitate day-case surgery.

Hemithyroidectomy for low-risk follicular carcinoma of the thyroid: results from a regional hospital.

INTRODUCTION: Excellent outcomes after conservative thyroid surgery for low-risk follicular thyroid carcinoma (FTC) have been reported from highly specialised centres. However, it is uncertain whether low-volume hospitals can achieve similar treatment results. METHODS: At our institution, 49 patients with FTC were treated during the period 1991-2014. Patients with minimally invasive FTC (MIFTC) were usually treated with hemithyroidectomy. The demographic data, pathology, treatment modality and oncological outcomes of these patients were retrospectively evaluated. RESULTS: The tumours were classified as Stage I in 40.8% of patients, Stage II in 32.7%, Stage III in 20.4% and Stage IV in 6.1%, according to the TNM classification system. Only 4 (8.2%) patients had widely invasive FTC (WIFTC). Vascular invasion or capsular invasion alone occurred in 9 (19.1%) and 19 (40.4%) patients, respectively, while 19 (40.4%) patients had simultaneous vascular and capsular invasions. 34 (69.4%) patients with MIFTC initially underwent hemithyroidectomy, while 15 (30.6%) patients underwent total thyroidectomy. Ten patients who underwent total thyroidectomy received radioactive iodine ablation. The mean follow-up duration was 86.9 ± 56.6 months. There was no disease-specific mortality, although two patients with WIFTC remained alive with disease at the end of the study. The five-, ten- and 15-year overall survival rates were 95%, 91% and 84%, respectively. Five patients from the hemithyroidectomy group died due to other illnesses with no evidence of FTC. CONCLUSION: Satisfactory disease control and excellent survival for MIFTC is achievable by hemithyroidectomy in community hospitals. Total thyroidectomy should be reserved for WIFTC or aggressive tumours with nodal or distant metastasis.

Improvement of anemia after parathyroidectomy in Chinese patients with renal failure undergoing long-term dialysis.

HYPOTHESIS: Most patients undergoing long-term dialysis are anemic because of underproduction of erythropoietin and its inhibition by high parathyroid hormone levels due to secondary hyperparathyroidism. Renal anemia can be improved by parathyroidectomy. DESIGN: Retrospective cohort study. SETTING: Regional hospital. PATIENTS: Twenty-three Chinese patients without a previous functioning renal transplant underwent parathyroidectomy for severe secondary hyperparathyroidism in a 3-year period. INTERVENTION: Total parathyroidectomy with or without parathyroid autograft at the forearm. MAIN OUTCOME MEASURES: The preoperative and 6-month postoperative hematological and biochemical variables were compared for any differences by means of a paired t test. RESULTS: The mean +/- SD follow-up duration was 17.7 +/- 8.1 (range, 6-34) months. Three patients (13%) developed persistent or recurrent hyperparathyroidism and 2 patients (9%) were biochemically hypoparathyroid. The other 18 patients (78%) were euparathyroid. Surgical morbidity was minimal; only 1 patient had complications, consisting of a postoperative fever of unknown origin that resolved with conservative treatment. The mean +/- SD hemoglobin level (8.6 +/- 2.1 vs 9.4 +/- 2.1 g/dL) but not the mean platelet level was significantly (P = .04) increased 6 months postoperatively. Likewise, the following other mean +/- SD biochemical values improved after surgery: parathyroid hormone (2235 +/- 500 vs 151 +/- 312 pg/mL; P<.001), alkaline phosphatase (645 +/- 349 vs 123 +/- 82 U/L; P<.001), calcium (10.8 +/- 4.0 vs 9.3 +/- 1.0 mg/dL; P<.001), phosphate (1.93 +/- 0.73 vs 1.50 +/- 0.51 mmol/L; P = .02), and albumin (3.5 +/- 0.5 vs 3.8 +/- 0.6 g/dL; P = .006). CONCLUSIONS: Parathyroidectomy is highly effective to control secondary hyperparathyroidism with an exceedingly low complication rate. The hemoglobin level was significantly elevated 6 months postoperatively. The long-term effect warrants future trials.

Sensation recovery improved by great auricular nerve preservation in parotidectomy: a prospective double-blind study.

BACKGROUND: The great auricular nerve (GAN) is frequently sacrificed during parotidectomy and causes sensory disturbance of the auricle. Our study is to investigate whether GAN preservation can improve the sensory recovery. METHODS: Patients undergoing superficial or total conservative parotidectomy for benign tumours were recruited consecutively from November 1998 to September 2001. Different sensory methods (light touch, two-point discrimination and sharp pain) of the auricle were evaluated by a designated physiotherapist preoperatively as well as at 1, 3, 6 and 12 months postoperatively. The patients and the physiotherapist were blinded to the integrity of the GAN. Long-term subjective assessment was also carried out beyond 2 years postoperatively. RESULTS: A total of 21 patients were recruited for the study. GAN were preserved in 10 patients. The mean follow up was 16 months (12-42 months). There was no difference in sex distribution, type of operation and pathology of parotid tumour between the two groups. No postoperative mortality occurred and postoperative morbidity did not differ between the two groups. Patients with GAN preserved had significantly better light touch and sharp pain recovery at 1 year postoperatively. Subjective assessment of sensory dysfunction also favoured GAN preservation. CONCLUSION: Great auricular nerve preservation minimizes the postoperative sensory disturbance and should be considered whenever tumour clearance is not compromised.

Complication rates of central compartment dissection in papillary thyroid cancer.

BACKGROUND: The benefits of central compartment dissection (CCD) in papillary thyroid carcinoma (PTC) are still debatable and should be weighed against its potential risks. We aim to compare the complication rates in total thyroidectomy with and without CCD for patients with PTC. METHODS: This is a retrospective study on prospectively collected data from our cancer registry over a 15-year period. Patients with pathologically proven PTC treated with total thyroidectomy alone or with CCD were included. CCD was performed at the operating surgeon's discretion. A total of 105 patients were included and divided into two groups for analysis: group A - total thyroidectomy alone (51 patients, 49%) and group B - total thyroidectomy with CCD (54 patients, 51%). The operative complications between the two groups were then evaluated. RESULTS: Overall, 6.9% and 0.98% patients had transient and permanent recurrent laryngeal nerve palsies, respectively. About 19.0% and 2.9% patients had transient and permanent hypoparathyroidism, respectively and 27.6% patients had parathyroid glands found to be included in the resected specimen. Complication rates in terms of transient or permanent recurrent laryngeal nerve palsy or hypoparathyroidism did not differ significantly between groups A and B. Within group B, 41 patients had unilateral CCD and 12 had bilateral CCD. Transient hypoparathyroidism was more frequent in bilateral CCD (50% versus 12.2%, P = 0.01). CONCLUSIONS: Total thyroidectomy with prophylactic unilateral CCD is a safe procedure for PTC without added complication rates compared with total thyroidectomy alone. It is recommended for patients with PTC and clinically negative neck lymph nodes.

Sentinel lymph node dissection in papillary thyroid carcinoma.

BACKGROUND: Occult lymph node (LN) metastasis is common in papillary thyroid carcinoma. Sentinel lymph node (SLN) biopsy has been proven to be successful and accurate to predict the nodal status in melanoma and breast cancer. We investigate the use of SLN in papillary thyroid carcinoma. METHODS: Patients of previously untreated papillary thyroid carcinoma, diagnosed preoperatively by fine-needle cytology without any palpable cervical LN are prospectively studied. Blue dye injection was utilized for the SLN biopsy followed by central compartment lymphadenectomy. The histopathological results of the SLN and lymphadenectomy specimens were compared. RESULTS: Fifteen consecutive patients underwent surgery including SLN biopsy for papillary thyroid carcinoma. Occult nodal metastases were identified in 10 patients (67%). The other five cases had no nodal metastasis. SLN were found in 10 cases. One, two and three SLN were present in three, three and four patients, respectively. SLN were located in the central compartment in eight cases. The SLN were found in the lateral compartment in one case. In the remaining one case, the SLN were found in both the central and lateral compartments. Of the group with found SLN, false negative occurred in one case. The overall accuracy of the SLN in predicting the nodal status was 90%. The sensitivity, specificity, positive predictive value and negative predictive value were 88%, 100%, 100% and 67%, respectively. No complications were directly related to SLN biopsy. CONCLUSION: Occult nodal spread is frequently encountered in papillary thyroid carcinoma. SLN biopsy is safe and feasible in papillary thyroid cancer, however further studies are necessary to improve the diagnostic accuracy prior to routine clinical use.

Acupuncture anaesthesia in inguinal hernia repair.

BACKGROUND: The present study was undertaken to evaluate the efficacy of acupuncture anaesthesia in inguinal hernia repair. METHODS: Twelve patients with non-recurrent inguinal hernia had Lichtenstein mesh repair under acupuncture anaesthesia. Selected acupuncture loci were stimulated with fine needles connected to low frequency current. Supplementary local anaesthetic was given when required. RESULTS: Four (33%) patients reported satisfactory analgesic effect throughout the operation without need for additional medication, eight (67%) patients experienced mild discomfort during the operation requiring 1-4 mL of 1% lignocaine injection. Blood pressure and heart rate were stable during the procedure. All patients were able to sit up and resume their diet immediately post-operatively. All but one patient were discharged on day one after the procedure, with no early or late complications reported. Most patients were satisfied with the analgesic effect of acupuncture anaesthesia. CONCLUSIONS: Acupuncture anaesthesia is a feasible anaesthetic option. It reduces the amount of local anaesthetic required, and thus the associated potential complications. It is effective in pain relief and inhibiting gastrointestinal upset. Postoperative recovery was rapid and complication free.