Geographic disparities in thyroid cancer staging at presentation: Insights from an Australian context.

BACKGROUND: Thyroid cancer diagnoses have increased over recent decades at a rate much higher than that of any other cancer in Australia. Rural patients are known to have reduced access to healthcare and may have different thyroid cancer presentation rates. This study examined the relationship between thyroid cancer diagnosis and patient rurality. METHODS: Data from the Australia and New Zealand Thyroid Cancer Registry from 2017 to 2022 were analyzed, stratifying patient postcodes into rurality groups using the Australian Statistical Geography Standard. The American Thyroid Association (ATA) guidelines were used to stratify risk categories and management to compare treatment adequacy between the groups. Statistical analysis assessed demographic, clinical, and management differences. RESULTS: Among 1766 patients, 70.6% were metropolitan (metro) and 29.4% were non-metropolitan (non-metro). Non-metro patients were older at diagnosis (median 56 vs. 50 years, p < 0.001), presented more frequently with T stage greater than 1 (stage 2-4, 41.9% vs. 34.8%, and p = 0.005), AJCC stage greater than 1 (stage 2-4, 18.5% vs. 14.6%, and p = 0.019), and cancers larger than 4 cm (14.3% vs. 9.9%, p = 0.005). No significant differences in treatment adequacy were observed between the groups for ATA low-risk cancers. CONCLUSIONS: Non-metropolitan patients in the registry present with more advanced thyroid cancer, possibly due to differences in healthcare access. Further research should assess long-term survival outcomes and influencing factors. Understanding the impact on patient outcomes and addressing healthcare access barriers can optimize thyroid cancer care across geographic regions in Australia.

The impact of delayed diagnosis and treatment due to COVID-19 on Australian thyroid cancer patients: a qualitative interview study.

OBJECTIVES: The study aims to investigate the perceptions of patients with thyroid cancer on the potential impact of diagnosis and treatment delays during the COVID-19 pandemic. DESIGN: This study involved qualitative semi-structured telephone interviews. The interviews were transcribed verbatim, analysed using the thematic framework analysis method and reported using the Consolidated Criteria for Reporting Qualitative Research. SETTING: Participants in the study were treated and/or managed at hospital sites across New South Wales and Victoria, Australia. PARTICIPANTS: 17 patients with thyroid cancer were interviewed and included in the analysis (14 females and 3 males). RESULTS: The delays experienced by patients ranged from <3 months to >12 months. The patients reported about delays to diagnostic tests, delays to surgery and radioactive iodine treatment, perceived disease progression and, for some, the financial burden of choosing to go through private treatment to minimise the delay. Most patients also reported not wanting to experience delays any longer than they did, due to unease and anxiety. CONCLUSIONS: This study highlights an increased psychological burden in patients with thyroid cancer who experienced delayed diagnosis and/or treatment during COVID-19. The impacts experienced by patients during this time may be similar in the case of other unexpected delays and highlight the need for regular clinical review during delays to diagnosis or treatment.

Patterns of breast reconstruction and the influence of a surgical multidisciplinary clinic.

BACKGROUND: Of the 40% of breast cancer patients who have a mastectomy as part of their surgical treatment, only approximately 29% have a breast reconstruction. In 2016, Alfred Health established a multidisciplinary surgical clinic with breast and plastic surgeons, aiming to improve interdisciplinary collaboration. This study aimed to assess the provision of breast reconstruction at an Australian tertiary public hospital and examine whether the multidisciplinary surgical clinic have improved our reconstructive service provision. METHODS: A retrospective cohort study of patients who underwent mastectomy at Alfred Health between October 2011 and September 2021 was conducted. Patients were divided into before and after groups, treated during the 5-year period before and after establishing the multidisciplinary clinic respectively. Demographic data, operative details, histopathology, and treatments were compared. RESULTS: Over the 10-year period, 423 mastectomies were performed for 351 patients. Of those, 153 patients underwent breast reconstruction, providing an overall reconstruction rate of 43.6%. There was a statistically significant increase in the breast reconstruction rate from 36.5% before to 53.4% after the creation of the multidisciplinary surgical clinic. Patient factors such as age and tumour receptor status did not differ significantly between the groups. CONCLUSION: The establishment of a surgical multidisciplinary clinic has led to a statistically significant increase in the rate of breast reconstruction from 36.5% to 53.4%, leading to improved healthcare provision for our patients. Factors identified to be associated with increased uptake in the reconstruction service include younger age and node negative disease.

How to do an ultrasound or computed tomography guided hook-wire localization excisional biopsy of non-palpable lymph nodes.

This article describes the use of USS or CT guided hook-wire localization to aid the excisional biopsy of non-palpable lymph nodes in the cervical, axillary and inguinal regions. This technique allows a more focussed surgical approach intra-operatively to reduce surgical time and morbidity for the patients.

Beware the recurrent 'benign' multinodular goitre.

BACKGROUND: The diagnosis of follicular carcinoma is often difficult to make on pathological analysis, as the histological distinction from follicular adenoma rests solely on the presence of capsular or vascular invasion. Even on retrospective review of the histopathology after the disease biology has declared itself as malignant, the pathological diagnosis of malignancy may not be possible to make. METHODS: We report three cases in which patients were initially diagnosed with benign follicular lesions, but re-presented with locally recurrent disease and a subsequent malignant disease course. RESULTS: We describe a rare entity of follicular thyroid carcinoma that demonstrates a locally recurrent and eventually metastatic disease phenotype, despite persistently benign pathological findings. CONCLUSION: We highlight that if local recurrence occurs in discrete anatomical tissue planes, or in the thyroid bed following open total thyroidectomy for 'benign multinodular goitre', the possibility of this rare presentation of follicular thyroid carcinoma should be considered.

Hereditary Endocrine Tumor Registries.

Context: Endocrine neoplasia syndromes are phenotypically complex, and there is a misconception that they are universally rare. Genetic alterations are increasingly recognized; however, true prevalence is unknown. The purpose of a clinical registry is to monitor the quality of health care delivered to a specified group of patients through the collection, analysis, and reporting of relevant health-related information. This leads to improved clinical practice, decision-making, patient satisfaction, and outcome. Objective: This review aims to identify, compare, and contrast active registries worldwide that capture data relevant to hereditary endocrine tumors (HETs). Methods: Clinical registries were identified using a systematic approach from publications (Ovid MEDLINE, EMBASE) peer consultation, clinical trials, and web searches. Inclusion criteria were hereditary endocrine tumors, clinical registries, and English language. Exclusion criteria were institutional audits, absence of clinical data, or inactivity. Details surrounding general characteristics, funding, data fields, collection periods, and entry methods were collated. Results: Fifteen registries specific for HET were shortlisted with 136 affiliated peer-reviewed manuscripts. Conclusion: There are few clinical registries specific to HET. Most of these are European, and the data collected are highly variable. Further research into their effectiveness is warranted. We note the absence of an Australian registry for all HET, which would provide potential health and economic gains. This review presents a unique opportunity to harmonize registry data for HET locally and further afield.

Artificial Intelligence for Pre-operative Diagnosis of Malignant Thyroid Nodules Based on Sonographic Features and Cytology Category.

BACKGROUND: Current diagnosis and classification of thyroid nodules are susceptible to subjective factors. Despite widespread use of ultrasonography (USG) and fine needle aspiration cytology (FNAC) to assess thyroid nodules, the interpretation of results is nuanced and requires specialist endocrine surgery input. Using readily available pre-operative data, the aims of this study were to develop artificial intelligence (AI) models to classify nodules into likely benign or malignant and to compare the diagnostic performance of the models. METHODS: Patients undergoing surgery for thyroid nodules between 2010 and 2020 were recruited from our institution's database into training and testing groups. Demographics, serum TSH level, cytology, ultrasonography features and histopathology data were extracted. The training group USG images were re-reviewed by a study radiologist experienced in thyroid USG, who reported the relevant features and supplemented with data extracted from existing reports to reduce sampling bias. Testing group USG features were extracted solely from existing reports to reflect real-life practice of a non-thyroid specialist. We developed four AI models based on classification algorithms (k-Nearest Neighbour, Support Vector Machine, Decision Tree, Naïve Bayes) and evaluated their diagnostic performance of thyroid malignancy. RESULTS: In the training group (n = 857), 75% were female and 27% of cases were malignant. The testing group (n = 198) consisted of 77% females and 17% malignant cases. Mean age was 54.7 ± 16.2 years for the training group and 50.1 ± 17.4 years for the testing group. Following validation with the testing group, support vector machine classifier was found to perform best in predicting final histopathology with an accuracy of 89%, sensitivity 89%, specificity 83%, F-score 94% and AUROC 0.86. CONCLUSION: We have developed a first of its kind, pilot AI model that can accurately predict malignancy in thyroid nodules using USG features, FNAC, demographics and serum TSH. There is potential for a model like this to be used as a decision support tool in under-resourced areas as well as by non-thyroid specialists.

Preoperative serum calcitonin may improve initial surgery for medullary thyroid cancer in patients with indeterminate cytology.

BACKGROUND: Medullary thyroid cancer (MTC) is rare, with poorer outcomes than differentiated thyroid cancer. We aimed to identify areas for improvement in the pre-operative evaluation of patients with possible MTC in a high-volume endocrine surgery unit in accordance with current practice guidelines. We hypothesised that the selective use of serum calcitonin (sCT) as a biomarker for possible MTC could guide the extent of initial surgical management. METHODS: We recruited MTC patients between 2000 and 2020 from the Monash University Endocrine Surgery Unit database. Demographics, tumour characteristics, pre-operative evaluation, operative management, and outcomes were analysed. RESULTS: Of 1454 thyroid cancer patients, 43 (3%) had MTC. Pre-operatively, 36 (84%) patients with MTC confirmed on cytology (28, 65%), elevated sCT (6, 14%) or RET mutation (2, 4%). Of these 36 patients, 31 (86%) had optimal extent of thyroidectomy and lymph node dissection (LND). Five (14%) had less than total thyroidectomy due to nerve injury. Thirty-four patients had compartmental LND. In the 12 (27%) patients with indeterminate or non-diagnostic cytology, 5 had elevated sCT and were managed as above. None of the remaining seven had LND, thus potentially suboptimal surgery. CONCLUSION: Our findings reflect the rarity of MTC, and the challenges of pre-operative diagnosis. The addition of sCT may improve surgical planning in patients with indeterminate cytology.

Hypotension in Posterior Retroperitoneoscopic Versus Transperitoneal Laparoscopic Adrenalectomy.

INTRODUCTION: Despite preoperative optimization, hemodynamic instability can be a major challenge during adrenalectomy. Even brief episodes of intraoperative hypotension can be associated with ischemia-reperfusion injury. This study aimed to compare intraoperative hemodynamic parameters between posterior retroperitoneoscopic adrenalectomy (PRA) and transperitoneal laparoscopic adrenalectomy (TPA). METHODS: This is a retrospective study of patients undergoing PRA and TPA without conversion or concomitant intraabdominal pathology from 2008 to 2019. The primary outcome was intraoperative hypotension defined by mean arterial pressure <60 mm Hg or the need for ≥1 intravenous vasopressors at least 30 min after anesthetic induction. RESULTS: Overall, 108 patients met the inclusion criteria; 33 (30.6%) had pheochromocytoma, 26 (24.1%) had aldosterone excess, 8 (7.4%) had corticosteroid excess, and 41 (38.0%) had nonfunctioning adrenal tumors. Of these, 68 (63.0%) underwent PRA and 40 (37.0%) underwent TPA. Age, sex, body mass index, preinduction blood pressure, number of preoperative antihypertensives, and histopathological diagnosis were similar in the two groups. Tumor size was greater in the TPA group. The presence of pheochromocytoma was an independent risk factor for hypotension. Multivariate analysis revealed that PRA was associated with a higher risk of experiencing a mean arterial pressure <60 mm Hg (odds ratio 4.44, 95% confidence interval 1.27-15.54, P = 0.02) and the need for ≥1 intravenous vasopressors (odds ratio 9.97, 95% confidence interval 3.34-29.78, P < 0.001) compared with TPA. CONCLUSIONS: Although PRA offers several advantages over TPA, it carries a greater risk of intraoperative hypotension. A prospective trial is required to validate these findings. Nevertheless, institution of risk reduction strategies is encouraged to be considered for individuals undergoing PRA.

Cancer in thyroglossal duct cysts.

BACKGROUND: Thyroglossal duct cysts (TDC) account for 7% of midline neck swellings. TDC carcinoma (TDCC) is rare, reported in 1% of all TDCs. We aimed to describe the incidence of TDCC, the accuracy of fine needle aspiration cytology (FNAC), and to identify suspicious, predictive ultrasound (USG) features. METHOD: A cross sectional study of TDC patients in the Monash University Endocrine Surgery Database from 2001 to 2021. RESULTS: Eighty-six patients had surgery for TDC, of median age 48 and a female preponderance (62%). Preoperative USG was used in 85% and FNAC in 57%. There were six cases (7%) of TDCC with papillary thyroid cancer (PTC). USG in five TDCC cases showed a solid nodule within the cyst wall. FNAC was undertaken in five TDCC cases from the solid nodule; malignant in one and suspicious for malignancy in two. Two TDCC patients had concurrent total thyroidectomy (TT), and three subsequently had a TT. Multifocal thyroid PTC was found in two patients. One patient had a recurrence in the lateral lymph nodes, nine years after excision of the TDCC and TT. All patients are alive and well with no distant metastases (median follow up 11 years). CONCLUSION: The 7% incidence of TDCC is higher than the usually reported 1% in the literature. We recommend a preoperative USG to evaluate the TDC, thyroid gland and cervical lymph nodes, and an FNAC to target the solid component of the TDC, and favour total thyroidectomy for all patients with TDCC.

Primary hyperparathyroidism in adults-(Part II) surgical management and postoperative follow-up: Position statement of the Endocrine Society of Australia, The Australian & New Zealand Endocrine Surgeons, and The Australian & New Zealand Bone and Mineral Society.

OBJECTIVE: To develop evidence-based recommendations to guide the surgical management and postoperative follow-up of adults with primary hyperparathyroidism. METHODS: Representatives from relevant Australian and New Zealand Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing eight key questions. RESULTS: Diagnostic imaging does not determine suitability for surgery but can guide the planning of surgery in suitable candidates. First-line imaging includes ultrasound and either parathyroid 4DCT or scintigraphy, depending on local availability and expertise. Minimally invasive parathyroidectomy is appropriate in most patients with concordant imaging. Bilateral neck exploration should be considered in those with discordant/negative imaging findings, multi-gland disease and genetic/familial risk factors. Parathyroid surgery, especially re-operative surgery, has better outcomes in the hands of higher volume surgeons. Neuromonitoring is generally not required for initial surgery but should be considered for re-operative surgery. Following parathyroidectomy, calcium and parathyroid hormone levels should be re-checked in the first 24 h and repeated early if there are risk factors for hypocalcaemia. Eucalcaemia at 6 months is consistent with surgical cure; parathyroid hormone levels do not need to be re-checked in the absence of other clinical indications. Longer-term surveillance of skeletal health is recommended. CONCLUSIONS: This position statement provides up-to-date guidance on evidence-based best practice surgical and postoperative management of adults with primary hyperparathyroidism.

Primary hyperparathyroidism in adults-(Part I) assessment and medical management: Position statement of the endocrine society of Australia, the Australian & New Zealand endocrine surgeons, and the Australian & New Zealand bone and mineral society.

OBJECTIVE: To formulate clinical consensus recommendations on the presentation, assessment, and management of primary hyperparathyroidism (PHPT) in adults. METHODS: Representatives from relevant Australian and New Zealand Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing nine key questions. RESULTS: PHPT is a biochemical diagnosis. Serum calcium should be measured in patients with suggestive symptoms, reduced bone mineral density or minimal trauma fractures, and in those with renal stones. Other indications are detailed in the manuscript. In patients with hypercalcaemia, intact parathyroid hormone, 25-hydroxy vitamin D, phosphate, and renal function should be measured. In established PHPT, assessment of bone mineral density, vertebral fractures, urinary tract calculi/nephrocalcinosis and quantification of urinary calcium excretion is warranted. Parathyroidectomy is the only definitive treatment and is warranted for all symptomatic patients and should be considered for asymptomatic patients without contraindications to surgery and with >10 years life expectancy. In patients who do not undergo surgery, we recommend annual evaluation for disease progression. Where the diagnosis is not clear or the risk-benefit ratio is not obvious, multidisciplinary discussion and formulation of a consensus management plan is appropriate. Genetic testing for familial hyperparathyroidism is recommended in selected patients. CONCLUSIONS: These clinical consensus recommendations were developed to provide clinicians with contemporary guidance on the assessment and management of PHPT in adults. It is anticipated that improved health outcomes for individuals and the population will be achieved at a decreased cost to the community.

Varied Recurrent Laryngeal Nerve Course Is Associated with Increased Risk of Nerve Dysfunction During Thyroidectomy: Results of the Surgical Anatomy of the Recurrent Laryngeal Nerve in Thyroid Surgery Study, an International Multicenter Prospective Anatomic and Electrophysiologic Study of 1000 Monitored Nerves at Risk from the International Neural Monitoring Study Group.

Background: The recurrent laryngeal nerve (RLN) can be injured during thyroid surgery, which can negatively affect a patient's quality of life. The impact of intraoperative anatomic variations of the RLN on nerve injury remains unclear. Objectives of this study were to (1) better understand the detailed surgical anatomic variability of the RLN with a worldwide perspective; (2) establish potential correlates between intraoperative RLN anatomy and electrophysiologic responses; and (3) use the information to minimize complications and assure accurate and safe intraoperative neuromonitoring (IONM). Methods: A large international registry database study with prospectively collected data was conducted through the International Neural Monitoring Study Group (INMSG) evaluating 1000 RLNs at risk during thyroid surgery using a specially designed online data repository. Monitored thyroid surgeries following standardized IONM guidelines were included. Cases with bulky lymphadenopathy, IONM failure, and failed RLN visualization were excluded. Systematic evaluation of the surgical anatomy of the RLN was performed using the International RLN Anatomic Classification System. In cases of loss of signal (LOS), the mechanism of neural injury was identified, and functional evaluation of the vocal cord was performed. Results: A total of 1000 nerves at risk (NARs) were evaluated from 574 patients undergoing thyroid surgery at 17 centers from 12 countries and 5 continents. A higher than expected percentage of nerves followed an abnormal intraoperative trajectory (23%). LOS was identified in 3.5% of NARs, with 34% of LOS nerves following an abnormal intraoperative trajectory. LOS was more likely in cases of abnormal nerve trajectory, fixed splayed or entrapped nerves (including at the ligament of Berry), extensive neural dissection, cases of cancer invasion, or when lateral lymph node dissection was needed. Traction injury was found to be the most common form of RLN injury and to be less recoverable than previous reports. Conclusions: Multicenter international studies enrolling diverse patient populations can help reshape our understanding of surgical anatomy during thyroid surgery. There can be significant variability in the anatomic and intraoperative characteristics of the RLN, which can impact the risk of neural injury.

Less extensive surgery for low-risk papillary thyroid cancers post 2015 American Thyroid Association guidelines in an Australian tertiary centre.

INTRODUCTION: The 2015 American Thyroid Association guidelines (ATA15) consider hemithyroidectomy (HT) a viable treatment option for low-risk papillary thyroid cancers (PTCs) between 1 and 4 cm. We aimed to examine the impact of ATA15 in a high-volume Australian endocrine surgery unit. METHODS: A retrospective study of all patients undergoing thyroidectomy from January 2010 to December 2019. INCLUSION CRITERIA: PTC histopathology, Bethesda V-VI, size 1-4 cm, and absence of clinical evidence of lymph node or distant metastases pre-operatively. Primary outcome was rate of HT before and after ATA15. RESULTS: Of 5408 thyroidectomy patients, 339 (6.3%) met the inclusion criteria - 186 (54.9%) pre-ATA15 (2010-2015) and 153 (45.1%) post-ATA15 (2016-2019). The patient groups were similar; there were no significant differences between groups in age, sex, tumour size, proportion with Bethesda VI cytology, compressive symptoms, or thyrotoxicosis. Post-ATA15, there was a significant increase in HT rate from 5.4% to 19.6% (P = 0.0001). However, there was no corresponding increase in completion thyroidectomy (CT) rate (50.0% versus 27.6%, P = 0.2). The proportion managed with prophylactic central neck dissection (pCND) fell from 80.5% to 10.8% (P < 0.0001). Pre-ATA15, the only factor significantly associated with HT was Bethesda V. In contrast, post-ATA15, HT was more likely in patients with younger age, smaller tumours, and Bethesda V. CONCLUSION: After the release of 2015 ATA guidelines, we observed a significant increase in HT rate and a significant decrease in pCND rate for low-risk PTCs in our specialised thyroid cancer unit. This reflects a growing clinician uptake of a more conservative approach as recommended by ATA15.

Hereditary Endocrine Tumors and Associated Syndromes: A Narrative Review for Endocrinologists and Endocrine Surgeons.

OBJECTIVE: Hereditary endocrine tumors (HET) were among the first group of tumors where predisposition syndromes were recognized. The utility of genetic awareness is having the capacity to treat at an earlier stage, screen for other manifestations and initiate family cascade testing. The aim of this narrative review is to describe the most common hereditary syndromes associated with frequently encountered endocrine tumors, with an emphasis on screening and surveillance. METHODS: A MEDLINE search of articles for relevance to endocrine tumors and hereditary syndromes was performed. RESULTS: The most common hereditary syndromes associated with frequently encountered endocrine tumors are described in terms of prevalence, genotype, phenotype, penetrance of malignancy, surgical management, screening, and surveillance. CONCLUSION: Medical practitioners involved in the care of patients with endocrine tumors should have an index of suspicion for an underlying hereditary syndrome. Interdisciplinary care is integral to successful, long-term management of such patients and affected family members.

Patient Reported Experience on Consenting for Surgery - Elective Versus Emergency Patients.

INTRODUCTION: Informed consent for surgery is a medical and legal requirement, but completing these does not necessarily translate to high patient satisfaction. This patient-reported experience study aimed to examine the surgical consent process, comparing the patients' experience in elective and emergency settings. METHODS: Over a 6-mo period, postoperative patients at The Alfred Hospital Breast and Endocrine Surgical Unit were invited to participate in a survey on the surgical consent process - including perceived priorities, information provided and overall experience. Standard statistical techniques were used, with a significant P-value of < 0.05. RESULTS: A total of 412 patients were invited, with 130 (32%) responses. More patients underwent elective surgery (N= 90, 69%) than emergency surgery (N = 40, 31%). Emergency patients were more likely to sign the consent form regardless of its contents (93% versus 39%, P < 0.001) and more likely to be influenced by external pressures (63% versus 1%, P < 0.001). Elective patients were more likely to want to discuss their surgery with a senior surgeon (74% versus 23%, P < 0.001) and more likely to seek advice from external sources (83% versus 10%, P < 0.001). Both groups highly valued the opportunity to ask questions (67% versus 63%, P = 0.65). CONCLUSION: This study shows patients have a range of different priorities in preparation for surgery. Therefore, each consent process should be patient-specific, and focus on providing the patient with quality resources that inform decision-making.

Challenges in diagnosis and management of a spiradenocarcinoma: a comprehensive literature review.

BACKGROUND: Spiradenocarcinoma is a rare skin adnexal neoplasm that may behave aggressively. It is often associated with a benign slow-growing spiradenoma that has undergone malignant transformation. Given the paucity of cases in the literature, there is a lack of consensus on treatment. METHODS: The terms 'malignant spiradenoma' or 'spiradenocarcinoma' were systematically used to search the PubMed, MEDLINE and Google Scholar databases. A total of 182 cases of spiradenocarcinoma were identified as eligible for this comprehensive literature review. RESULTS: Spiradenocarcinoma was commoner in older age and Caucasian race. In most cases, surgical excision for local disease is the mainstay of treatment. Lymph node dissection is usually reserved for those with suspected or confirmed lymph node metastases. High rates of local recurrence (20.8%), metastasis (37.4%) and mortality (19.1%) were identified, prompting some authors to suggest regular follow up including chest X-rays and liver function tests. CONCLUSIONS: Patients with spiradenocarcinoma may benefit from a magnetic resonance imaging and fluorodeoxyglucose-positron emission tomography/computed tomography to establish the extent of disease. We recommend wide local excision as the treatment of choice to achieve surgical margins of ≥1 cm, with node resection to be determined on a case-to-case basis. Regular follow up is important given the high rate of local recurrence, metastasis and mortality. This should include an examination of the regional lymph nodes. Further research is required to refine an evidence-based approach to spiradenocarcinoma.