Surgical treatment and prognosis values of extranodal extension to recurrent laryngeal nerve in papillary thyroid carcinoma.

PURPOSE: Recurrent laryngeal nerve (RLN) invasion by extranodal extension (ENE) is a rare condition that may occur in papillary thyroid cancer (PTC), and it has never been characterised in the literature.Our research aims to investigate the clinical significance of ENE to RLN including its effect on vocal cord function, relationship with the aggressive behaviour of PTC, and optimal surgical methods. METHODS: A total of 3119 patients, including 2868 patients without RLN invasion, 251 patients with RLN invasion [categorised into the ENE invasion group (n = 55) and extrathyroidal extension (ETE) invasion group (n = 196)] were analyzed retrospectively. Data on clinicopathological characteristics, vocal cord paralysis (VCP), postoperative complications, surgical methods, rates of recurrence and metastasis were collected. Predictive disease-free survival (DFS) was analysed using the Kaplan-Meier method. RESULTS: The ENE invasion group showed a similar rate of VCP and DFS compared with the ETE invasion group (P = 0.15, P = 0.38, respectively). Sharp separation applied on the invaded nerves preserves the visual integrity of the RLN without significantly reducing the DFS (P > 0.05). ETE or ENE to RLN, lymph nodes metastasis (LNM), and T4 stage were independent factors for total recurrence [P = 0.04, hazard ratio (HR), 1.97 (1.04-3.75); P = 0.00, HR, 4.63 (2.24-9.54); P = 0.00, HR, 3.63 (1.94-6.77); P = 0.00, HR, 6.1 (3.24-11.50)]. RLN invasion, both by ETE or ENE, was significantly associated with reduced DFS (P = 0.00; P = 0.00, respectively). CONCLUSIONS: ENE to RLN, while rare, has not previously been well-studied. Our interesting premise and important findings including ENE to RLN has the same poor prognostic impact on recurrence as does invasion of the RLN by ETE and surgical management for the invaded RLN that preserves its visual integrity without compromising DFS. Those novel findings indicate that ENE to RLN could be considered as an additional factor beyond post-operative disease status and risk stratification, and it would be a valuable addition to further individualise treatment/surveillance for PTC.

Diagnostic and prognostic value of preoperative systemic inflammatory markers in anaplastic thyroid cancer.

BACKGROUND: Easily accessible, generalized, and inexpensive methods are expected to differentiate anaplastic thyroid carcinoma (ATC) from advanced differentiated thyroid cancer (aDTC). We aimed to explore potential diagnostic and prognostic value of systematic inflammatory markers (SIMs) in ATC and aDTC. METHODS: About 22 ATC, 101 aDTC, and 100 matched early DTC patients were analyzed retrospectively. SIMs included the comprehensive index, neutrophil-monocyte-platelet-to-lymphocyte ratio (NMPLR) and the previously reported ones. Receiver operating characteristic, Kaplan-Meier, and COX regression analyses were mainly conducted. RESULTS: NMPLR exhibited the highest area under the curve value 0.806 (P < .0001) to diagnose ATC from aDTC. NMPLR was identified as an independent risk factor for overall survival (OS) (hazard ratio [HR]: 47.821, 95% confidence interval [CI], 2.863-798.765, P = .007) in ATC, as well as for OS (HR: 7.360, 95% CI, 1.620-33.430, P = .010) and recurrence-free survival (HR: 4.172, 95% CI, 1.139-15.286, P = .031) in aDTC. Taken both refractory types (ATC and aDTC) together, NMPLR could independently predict OS (HR: 6.470; 95% CI, 2.134-19.616; P = .001). CONCLUSION: NMPLR is a generalized index. It showed excellent potential in differential diagnosis and survival prediction in refractory thyroid cancer. However, it needs to be validated in larger cohort and clinical practice.

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

The value of total tumor diameter in unilateral multifocal papillary thyroid carcinoma: a propensity score matching analysis.

Background: Tumor multifocality is frequently observed in papillary thyroid carcinoma (PTC). However, the maximum tumor diameter (MTD), currently utilized in various staging schemes, might not accurately indicate the level of aggressiveness exhibited by multifocal tumors. We aimed to investigate the relationship between total tumor diameter (TTD) and clinicopathological features of papillary thyroid carcinoma. Methods: Retrospective data analysis was done on 1936 individuals who underwent complete thyroidectomy for PTC. Patients were classified into subgroups according to unilateral multifocality, central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM). The relationships of clinicopathological features among these groups were analyzed. Results: Unilateral multifocality was observed in 117 patients. The clinicopathological features of the unilateral multifocal PTC were similar to the unifocal PTC with approximate TTD. The unilateral multifocality played no independent role in CLNM and LLNM. Moreover, the efficiency of TTD in predicting CLNM and LLNM was significantly higher than that of MTD. Conclusion: In the case of unilateral multifocal PTC, TTD is a more accurate indicator of the biological characteristics of the tumor than MTD.

The Effects of Radioiodine Therapy on the Recovery of Parathyroid Function in Patients with Protracted Hypoparathyroidism after Total Thyroidectomy for Papillary Thyroid Carcinoma.

BACKGROUND: To determine the effect of 131I treatment on postoperative parathyroid function and the timing of recovery of parathyroid function (RPF) in patients with protracted hypoPT. METHODS: 260 patients with papillary thyroid cancer (PTC) were retrospectively analyzed, including 166 patients treated with radioactive iodine-131 (131I) classified into the 131I group and 94 patients without 131I treatment classified into the control group. Data on clinicopathological characteristics, demographics, dose and interval time of 131I treatment, number of parathyroid glands remaining in situ (PGRIS), occurrence of hypoPT, duration of RPF, preoperative and postoperative levels of Ca and PTH were collected. RESULTS: The patients in the 131I group showed a higher persistent hypoPT rate than those in the control group (p = 0). The PGRIS and total number of PG were significantly higher in patients who recovered from protracted HypoPT (p = 0.02; p = 0.03). PGRIS and 131I treatment [1 ∼ 2 VS 0, p = 0.03, OR 3.19; 3 ∼ 4 VS 0, p = 0.02, OR3.62; p = 0.02, OR 1.98, respectively] were independent factors influencing postoperative persistent hypoPT. The timing of RPF differed significantly for patients in the control group compared to those in the 131I group [p = 0.00]. CONCLUSIONS: We found that 131I treatment significantly prolonged the RPF of patients with protracted hypoPT and caused late RPF (even beyond 12 months). The diagnosis of "permanent" hypoPT should be cautiously made at least 12 months after surgery, especially in patients who receive 131I treatment.

Rapidly changing coal-related city-level atmospheric mercury emissions and their driving forces.

The up-to-date city-level mercury emission inventory is essential for effective mitigation policy designs due to rapid changes in energy consumption and industrial structures in Chinese cities. This study updated the atmospheric mercury emission inventory in 2015 based on the most recent information on plant-specific air pollution control devices (APCDs) and coal consumption for 45 sectors in 215 Chinese cities. Total emissions were estimated at 218 t with an uncertainty range of - 54.0% to 147%, to which coal-fired industrial boilers (CFIBs) contributed 58.1%, followed by coal-fired power plants (CFPPs, 32.7%). Mercury emissions varied significantly among cities, ranging from 0.0218 to 6.89 t. The Logistics Mean Division Index (LMDI) model was then applied to identify key factors driving mercury emission changes in 50 representative cities from 2010 to 2015. Although coal consumption increased by nearly one fifth across the 50 cities, their total emissions declined by 2.36%, largely due to energy structure adjustments and widespread installations of more efficient APCDs. However, key drivers of mercury mitigation differed widely between the cities, being driven by energy intensity improvements in Chongqing and Guangzhou (Guangdong province) and by energy structure adjustments in Wuhan (Hubei province) and Yinchuan (Ningxia province). Mitigation strategies should be tailored to reflect these differences.

Bioenergy in China: Evaluation of domestic biomass resources and the associated greenhouse gas mitigation potentials.

As bioenergy produces neutral or even negative carbon emissions, the assessment of biomass resources and associated emissions mitigation is a key step toward a low carbon future. However, relevant comprehensive estimates lack in China. Here, we measure the energy potential of China's domestic biomass resources (including crop residues, forest residues, animal manure, municipal solid waste and sewage sludge) from 2000 to 2016 and draw the spatial-temporal variation trajectories at provincial resolution. Scenario analysis and life cycle assessment are also applied to discuss the greenhouse gas mitigation potentials. Results show that the collectable potential of domestic biomass resources increased from 18.31 EJ in 2000 to 22.67 EJ in 2016 with overall uncertainties fluctuating between (-26.6%, 39.7%) and (-27.6%, 39.5%). Taking energy crops into account, the total potential in 2016 (32.69 EJ) was equivalent to 27.6% of China's energy consumption. If this potential can be realized in a planned way to displace fossil fuels during the period 2020-2050, cumulative greenhouse gas emissions mitigation would be in the range of 1652.73-5859.56 Mt CO2-equivalent, in which the negative greenhouse gas emissions due to the introduction of bioenergy with carbon capture and storage would account for 923.78-1344.13 Mt CO2-equivalent. Contrary to increasing bioenergy potentials in most provinces, there are declining trends in Tibet, Beijing, Shanghai and Zhejiang. In addition, Yunnan, Sichuan and Inner Mongolia would have the highest associated greenhouse gas mitigation potentials. This study can provide valuable guidance on the exploitation of China's untapped biomass resources for the mitigation of global climate change.