Survey of Korean head and neck surgeons and endocrinologists for the surgical extent of 1.5 and 2.5 cm papillary thyroid carcinoma.

Background: The surgical extent of 1-4 cm papillary thyroid carcinoma (PTC) is controversial. We aimed to determine the current trend in the extent of thyroidectomy and prophylactic central neck dissection (pCND) for 1.5 and 2.5 cm PTC, which are the most clinically controversial sizes. Methods: The questionnaire was sent to 342 Korean Society of Head and Neck Surgery and 160 one branch of Korean Endocrine Society members from June to July 2021 by e-mail. A questionnaire included extent of thyroidectomy [hemithyroidectomy (Hemi) vs. total thyroidectomy (TT)] and pCND according to the tumor location and degree of extrathyroidal extension (ETE) at 1.5 or 2.5 cm PTC. We compared the proportion of respondents' preference for each scenario. Results: Fifty-seven of 342 surgeons and twenty-seven of 160 endocrinologists responded to the questionnaire. At 1.5 and 2.5 cm PTC without ETE, both groups preferred Hemi, and there was no difference between the groups. When 1.5 or 2.5 cm PTC with anterior minimal ETE was suspected, the preference for Hemi by endocrinologists was significantly lower than that by surgeons (P<0.05). When anterior and posterior gross ETE were suspected, TT was preferred in both groups. When anterior gross ETE was suspected, the preference for Hemi by endocrinologists was significantly lower than that by surgeons (P<0.05). There was no difference between the groups in the posterior gross ETE. Surgeons preferred Hemi and endocrinologists preferred TT for a 1.5 cm PTC located in the isthmus. The pCND showed a similar pattern in both groups according to the size and location of the tumor and the degree of ETE. The proportion of Hemi did not differ between high-experience and low-experience endocrinologists. Also, there was no significant difference in preference for surgical extent between low-volume and high-volume surgeons. Conclusions: TT was frequently preferred in tumors with a large size or gross ETE, and pCND was frequently preferred in cases of suspected gross ETE. This study shows as the extent of thyroid surgery may differ between endocrinologists and surgeons and this could be confusing to patient and affect the patient outcomes. Therefore, multidisciplinary approach considering the extent of surgery for thyroid cancer is recommended.

Risk factors for second primary malignancies following thyroid cancer: a nationwide cohort study.

Objective: Thyroid cancer survivors have a high risk of second primary malignancies (SPMs). We aimed to evaluate the site-specific incidence, prognosis, and risk factors for metachronous SPMs following thyroid cancer. Design: A nationwide cohort study. Methods: This study included data from the Korea National Health Insurance Service (between 2002 and 2018). Exposure to diagnostic radiation was defined by the number of computed tomography (CT) and positron emission tomography-CT scans after the index date. A cumulative radioactive iodine (RAI) dose >100 mCi was considered high-dose RAI. Results: During the median 6 years of follow-up, among 291 640 patients, 13 083 (4.5%) developed SPMs. Thyroid cancer survivors had a 26% increased risk of SPMs compared with the general population (standardized incidence ratio: 1.26; 95% CI: 1.22-1.29). Furthermore, those with SPMs had a significantly poorer survival rate than those without SPMs (hazard ratio: 11.85; 95% CI: 11.21-12.54; P < 0.001). Significantly elevated risks were observed in myeloid leukemia and 13 solid cancer sites: lip, salivary gland, small intestine, larynx, lung, mediastinum and pleura, mesothelium, breast, corpus uteri, ovary, prostate, kidney, and bladder. Frequent diagnostic medical radiation exposure and high-dose RAI therapy were independent risk factors for several SPMs, including the cancer of salivary gland, lung, mediastinum and pleura, breast, kidney, and bladder, as well as myeloid leukemia. Conclusions: Frequent diagnostic radiation exposure and high-dose RAI therapy are independent risk factors for SPM following thyroid cancer. Clinicians need to consider minimizing unnecessary diagnostic radiation exposure and administering a high dose RAI only when justified in patients with thyroid cancer.

Investigation of attachment location of adhesive skin electrodes for intraoperative neuromonitoring in thyroid surgery: Preclinical and clinical studies.

BACKGROUND: Recently, adhesive skin electrodes have been reported to be useful for recording electromyographic signals from intrinsic laryngeal muscles for intraoperative neuromonitoring in thyroid surgery and have shown good results compared to existing recording methods. In this study, we investigated the optimal attachment location of adhesive skin electrodes for intraoperative neuromonitoring in both porcine models and human cases. METHODS: Attachment locations were divided vertically into upper, middle, and lower locations and horizontally into medial and lateral locations to determine the optimal location of placing adhesive skin electrodes preclinically in four porcine models. This study included a total of 78 patients who underwent thyroidectomy under intraoperative neuromonitoring with adhesive skin electrodes. Sixteen patients were monitored using both adhesive skin electrodes and an electromyographic endotracheal tube. Two pairs of skin electrodes were attached to the level of the thyroid cartilage lamina. Evoked electromyographic data, including data on mean amplitude and latency, obtained by stimulating the recurrent laryngeal nerve and vagus nerve, were collected. RESULTS: Lateral attachment of adhesive skin electrodes showed significantly higher evoked amplitudes than medial attachment in both animal models and human patients. In cases where skin electrodes and an electromyographic endotracheal tube were used together, the electromyographic endotracheal tube showed a significantly higher amplitude than skin electrodes, and laterally attached skin electrodes showed a significantly higher amplitude than medially attached skin electrodes. CONCLUSION: Intraoperative neuromonitoring using adhesive skin electrodes was feasible in both animal models and human patients. We suggest that it would be better to attach adhesive skin electrodes to the lateral side of the thyroid cartilage lamina. Lateral attachment closer to the cricoarytenoid joint may be better for measuring muscle movement around the cricoarytenoid joint.

Ultrasound Echogenicity of Papillary Thyroid Cancer Is Affected by Tumor Growth Patterns and Tumor Fibrosis.

BACKGROUND/AIM: The association between preoperative ultrasound (US) echogenicity and histopathological characteristics of papillary thyroid cancer (PTC) has been rarely investigated is not well characterized. This study evaluated a relationship between the clinical characteristics of PTC, histopathological phenomena including tumor growth patterns (TGPs) and tumor fibrosis (TF), and US echogenicity. PATIENTS AND METHODS: In total, 170 patients with PTC (<2 cm) underwent total thyroidectomy with central neck dissection. Demographics, US echogenicity, tumor size, extra-thyroidal extension (ETE), lymph node metastasis (LNM) within the central and lateral neck, TGPs, and TF percentage were reviewed. RESULTS: Patients with TGP II (encapsulated growth with partial pericapsular extension) and III (infiltrative growth) were more frequently burdened by ETE and lateral neck LNM compared to patients with TGP I (encapsulated growth with a well-defined cystic or solid characteristic). Older age was significantly deterministic of TGP III, and male gender and higher TF percentage were independent risk factors for lateral neck LNM. TGP III and TF were independent determining factors for marked hypoechogenicity on US. CONCLUSION: PTC with TGP II and III and higher tumor fibrosis exhibited more aggressive clinicopathologic behaviors. TGP III and TF were determinants for marked hypoechogenicity.

Risk factors of suprasternal lymph node metastasis in papillary thyroid carcinoma with clinical lateral cervical lymph node metastasis.

BACKGROUND: Metastatic lymph nodes are occasionally found in suprasternal lymph nodes in patients with papillary thyroid cancer (PTC). However, limited studies have examined these lymph nodes thus far. Therefore, we investigated the frequency and risk factors of suprasternal lymph node metastasis in patients with PTC and lateral cervical lymph node metastasis. METHODS: A total of 85 patients with cN1b PTC underwent total thyroidectomy, central neck dissection, and ipsilateral selective neck dissection including suprasternal lymph node dissection. We analyzed the correlation between suprasternal lymph node metastasis and sex, age, tumor characteristics, and cervical lymph node metastasis status. RESULTS: Eleven (12.9%) patients had pathological suprasternal lymph node metastasis. Suprasternal lymph node metastasis was associated with tumors located in the inferior pole of the thyroid gland and level IV lymph node metastasis (P=0.005 and 0.014, respectively). Receiver operating characteristic curve analysis indicated that two or more level IV metastatic lymph nodes had the best predictive value for suprasternal lymph node metastasis (P<0.001). CONCLUSIONS: In patients with cN1b PTC, especially those with tumors in the inferior pole of the thyroid gland or level IV lymph node metastasis, greater attention should be paid to the suprasternal lymph nodes and suprasternal lymph node dissection should be routinely included as part of selective neck dissection.

Diagnostic accuracy of C-11 choline and C-11 acetate for lymph node staging in patients with bladder cancer: a systematic review and meta-analysis.

OBJECTIVE: We aimed to assess the diagnostic accuracy of C-11 choline and C-11 acetate positron emission tomography/computed tomography (PET/CT) for lymph node (LN) staging in bladder cancer (BC) patients through a systematic review and meta-analysis. METHODS: The MEDLINE, EMBASE, and Cochrane Library database, from the earliest available date of indexing through June 30, 2017, were searched for studies evaluating the diagnostic performance of C-11 choline and C-11 acetate PET/CT for LN staging in BC. We determined the sensitivities and specificities across studies, calculated positive and negative likelihood ratios (LR+ and LR-), and constructed summary receiver operating characteristic curves. RESULTS: Across 10 studies (282 patients), the pooled sensitivity was 0.66 (95% CI 0.54-0.75) without heterogeneity (χ2 = 12.4, p = 0.19) and a pooled specificity of 0.89 (95% CI 0.76-0.95) with heterogeneity (χ2 = 29.1, p = 0.00). Likelihood ratio (LR) syntheses gave an overall positive likelihood ratio (LR+) of 5.8 (95% CI 2.7-12.7) and negative likelihood ratio (LR-) of 0.39 (95% CI 0.28-0.53). The pooled diagnostic odds ratio (DOR) was 15 (95% CI 6-38). In meta-regression analysis, the study design (prospective vs retrospective) was the source of the study heterogeneity. CONCLUSION: C-11 choline and C-11 acetate PET/CT shows a low sensitivity and moderate specificity for the detection of metastatic LNs in patients with BC. Moreover, heterogeneity among the studies should be considered a limitation. Further large multicenter studies would be necessary to substantiate the diagnostic accuracy of C-11 choline and C-11 acetate PET/CT for this purpose.

Diagnostic accuracy of 18F-FDG PET or PET/CT for the characterization of adrenal masses: a systematic review and meta-analysis.

OBJECTIVE: We aimed to explore the role of the diagnostic accuracy of 18F fluodeoxyglucose PET (18F-FDG PET) or PET/CT for characterization of adrenal lesions through a systematic review and meta-analysis. METHODS: The MEDLINE, EMBASE, and Cochrane Library database, from the earliest available date of indexing through 30 April 2017, were searched for studies evaluating the diagnostic performance of 18F-FDG PET or PET/CT for characterization of adrenal lesions. We determined the sensitivities and specificities across studies, calculated positive and negative likelihood ratios (LR + and LR-), and constructed summary receiver operating characteristic curves. RESULTS: Across 29 studies (2421 patients), the pooled sensitivity for 18F-FDG PET or PET/CT was 0.91 [95% CI (0.88-0.94)] with heterogeneity (χ2 = 141.8, p = 0.00) and a pooled specificity of 0.91 [95% CI (0.87-0.93)] with heterogeneity (χ2 = 113.7, p = 0.00). Likelihood ratio (LR) syntheses gave an overall positive likelihood ratio (LR+) of 9.9 [95% CI (7.1-13.7)] and negative likelihood ratio (LR-) of 0.09 [95% CI (0.07-0.13)]. The pooled diagnostic odds ratio was 105 [95% CI (63-176)]. In metaregression analysis, study design, publication year, study location (western vs others), interpretation criteria of PET or PET/CT images, quantification of PET or PET/CT [SUVmax (maximum standardized uptake value) vs SUV (standardized uptake value) ratio], patient group, and analysis method (patient-based vs lesion-based) were the sources of the study heterogeneity. However, in multivariate metaregression, no definite variable was the source of the study heterogeneity. CONCLUSION: 18F-FDG PET or PET/CT demonstrated good sensitivity and specificity for the characterization of adrenal masses. At present, the literature regarding the use of 18F-FDG PET or PET/CT for the characterization of adrenal masses remains still limited; thus, further large multicenter studies would be necessary to substantiate the diagnostic accuracy of 18F-FDG PET or PET/CT characterization of adrenal masses. Advances in knowledge: 18F- FDG PET or PET/CT showed good sensitivity and specificity for the characterization of adrenal masses and could provide additional information for that purpose.

Prognostic implication of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography in patients with recurrent papillary thyroid cancer.

BACKGROUND: Fluorine-18 fluorodeoxyglucose positron emission tomography/CT (18 F-FDG PET/CT) has been widely accepted as an effective method for detecting recurrent papillary thyroid cancer (PTC) in patients with increased serum thyroglobulin (Tg) or Tg antibody (TgAb) levels and negative whole-body scintigraphy (WBS) results. The role of WBS as a diagnostic tool in detecting recurrence has relatively decreased recently. However, only a few studies have examined the usefulness of 18 F-FDG PET/CT for evaluating patients with recurrent PTC, regardless of the WBS results. The purpose of this analysis was to evaluate the diagnostic value and prognostic role of 18 F-FDG PET/CT for patients with recurrent PTC, irrespective of their WBS results. METHODS: Sixty-six patients with locoregional recurrent PTC who underwent 18 F-FDG PET/CT and neck CT within 6 months before surgical treatment were included in this retrospective analysis. Imaging findings were compared with postoperative histopathologic results. The diagnostic values of 18 F-FDG PET/CT and neck CT were compared according to the serum Tg and TgAb levels and cervical levels. Each patient's status at the last follow-up was also reviewed, and survival probabilities were estimated using the Kaplan-Meier plot. RESULTS: The sensitivity, specificity, and diagnostic accuracy of 18 F-FDG PET/CT for the entire patient group were 38.5%, 90.2%, and 58.3%, respectively. The corresponding neck CT values were 55.0%, 85.7%, and 66.7%, respectively. According to the serum Tg and TgAb levels, except for the specificity, most diagnostic values of 18 F-FDG PET/CT were worse than those of the neck CTs, with or without statistical significance. For the high maximum standardized uptake value (SUVmax) group (SUVmax >10) and the low SUVmax group, the median locoregional disease-free survival times were 33.3 months and 81.8 months, respectively (P < .001). CONCLUSION: The diagnostic value of 18 F-FDG PET/CT for localizing recurrent lesions was worse than that of the neck CT, irrespective of the WBS results. However, patients with a higher SUVmax showed a significantly worse prognosis than did those with a lower SUVmax. Therefore, we suggest that, in patients with recurrent PTC, 18 F-FDG PET/CT should be considered for prognostication rather than diagnosis.

Metastatic lymph node status in the central compartment of papillary thyroid carcinoma: A prognostic factor of locoregional recurrence.

BACKGROUND: The purpose of this study was to present our focus on the lymph node status in the central compartment and evaluate the relevant factors and disease recurrence. METHODS: Between January 2004 and December 2009, 1040 patients were diagnosed with papillary thyroid carcinoma (PTC) and underwent surgery. RESULTS: The number of metastatic lymph nodes was a significant predictor for recurrence conferring a hazard ratio of 1.36 (confidence interval = 1.103-1.680; p = .004). The receiver operating characteristic (ROC) curve was calculated to determine the cutoff number of lymph nodes that predicted recurrence with the highest sensitivity and specificity (area under the ROC curve, 0.794; SE, 0.077; p = .001). The sensitivity/specificity of >3 metastatic lymph nodes for predicting recurrence was 63.6%/77.0%, respectively. CONCLUSION: The number of metastatic lymph nodes in the central compartment was a statistical significant predictive factor associated with disease recurrence. Further study is required to confirm the relationship between the number of lymph nodes and disease recurrence. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1172-E1176, 2016.

Lymph node status of lateral neck compartment in patients with N1b papillary thyroid carcinoma.

Conclusion Loco-regional recurrence-free survival was significantly decreased in the papillary thyroid cancer patients with > 6 metastatic lymph nodes and a lymph node ratio > 0.22. Also, the risk of lung metastasis was significantly increased in cases with bilateral neck node metastases. Objective This study focused on the metastatic lymph node status of the lateral neck compartment to understand its prognostic significance for loco-regional recurrence and distant metastasis. Methods Between January 2004 and December 2009, 1040 patients were diagnosed with papillary thyroid cancer and underwent treatment. Results In a multivariate analysis, sex, the number of metastatic lymph nodes, and the lymph node ratio was significantly associated with loco-regional recurrence. The sensitivity/specificity of > 6 metastatic lymph nodes for predicting recurrence was 64.0%/69.7%. The 5-year loco-regional recurrence-free survival of patients with 0-6 metastatic lymph nodes and > 6 metastatic lymph nodes were 93.4% and 79.2%, respectively. The 5-year loco-regional recurrence-free survival of patients with a lymph node ratio ≤ 0.22 and a lymph node ratio > 0.22 were 97.1% and 78.8%, respectively. In the multivariate analysis, only bilateral neck node metastases were significantly associated with lung metastasis.

Correlation between postpartum depression and premenstrual dysphoric disorder: Single center study.

OBJECTIVE: To describe the prevalence and correlates of the postpartum depression and premenstrual dysphoric disorder. METHODS: One hundred sixty six women were assessed around 10th to 14th days after delivery in Gangneung Asan Hospital, Korea, from September 2011 to March 2012. We checked their risk factors for postpartum depressive disorders using the Beck Depression Inventory and the Edinburgh Postnatal Depression Scale. Premenstrual dysphoric disorder was evaluated retrospectively and was defined as having more than 5 of the following 10 symptoms: breast tenderness, bloating, headache, peripheral edema (hand and foot), depressive symptoms, anger, irritability, anxiety, oversensitivity, and exaggerated mood swings. RESULTS: The prevalence rate of postpartum depression using the Edinburgh Postnatal Depression Scale ≥10 and Beck Depression Inventory ≥10 was 13.9% (23/166). We found statistical differences (P<0.01) between the postpartum depression group and the postpartum non-depression group in smoking history, past history of psychiatric problems, and level of marital satisfaction. The prevalence rate of premenstrual syndrome (PMS) was 9% (15/166) and among 23 women in the postpartum depression group, eight were determined to have premenstrual dysphoric disorder, yielding a prevalence rate of 34.8% (8/23). Among 143 women in the postpartum non-depression group, seven were determined to have PMS, yielding a prevalence rate of 4.9% (7/143). A correlation between postpartum depression and PMS was thus found (P<0.01). CONCLUSION: PMS appears to be associated with postpartum depression. This means that a hormone-related etiology appears to be one risk factor for postpartum depression.

Association of the Preoperative Neutrophil-to-ymphocyte Count Ratio and Platelet-to-Lymphocyte Count Ratio with Clinicopathological Characteristics in Patients with Papillary Thyroid Cancer.

BACKGROUND: Several inflammatory biomarkers, especially a high preoperative neutrophil-to-lymphocyte count ratio (NLR) and platelet-to-lymphocyte count ratio (PLR), are known to be indicator of poor prognosis in several cancers. However, very few studies have evaluated the significance of the NLR and PLR in papillary thyroid cancer (PTC). We evaluated the association of the preoperative NLR and PLR with clinicopathological characteristics in patients with PTC. METHODS: This study included 1,066 female patients who underwent total thyroidectomy for PTC. Patients were stratified into 4 quartiles by preoperative NLR and PLR. And the combination of preoperative NLR and PLR was calculated on the basis of data obtained value of tertile as follows: patients with both an elevated PLR and an elevated NLR were allocated a score of 2, and patients showing one or neither were allocated a score of 1 or 0, respectively. RESULTS: The preoperative NLR and PLR were significantly lower in patients aged ≥45 years and in patients with Hashimoto's thyroiditis. The PLR was significantly higher in patients with tumor size >1 cm (P=0.021).When the patients were categorized into the aforementioned four groups, the group with the higher preoperative PLR was found to have a significantly increased incidence of lateral lymph node metastasis (LNM) (P=0.018). However, there are no significant association between the combination of preoperative NLR and PLR and prognostic factors in PTC patients. CONCLUSION: These results suggest that a preoperative high PLR were significant associated with lateral LNM in female patients with PTC.

Change in quality of life in patients with acromegaly after treatment with octreotide LAR: first application of AcroQoL in Korea.

OBJECTIVES: This study was designed to investigate changes in health-related quality of life (HRQoL) of patients with acromegaly in Korea after medical treatment with octreotide LAR using the validated Korean version of the acromegaly quality of life questionnaire (AcroQoL). DESIGN: A prospective, open-label, single-arm study. SETTING: 11 tertiary centres in Korea. PARTICIPANTS: 58 Korean patients (aged 21-72 years) who were newly diagnosed with acromegaly between 2009 and 2012 were prescribed octreotide LAR 20 mg at the time of enrolment. During 24 weeks of observation, AcroQoL survey questionnaires and measurement of growth hormone insulin-like growth factor 1(GH/IGF-I) were performed at baseline, week 12 and week 24. MAIN OUTCOME MEASURES: We assessed the HRQoL of Korean patients with acromegaly after medical treatment with octreotide LAR using the validated Korean version of the AcroQoL questionnaire. RESULTS: Patients had a mean age of 47.2 years (29 males), and GH and IGF-I significantly decreased during the first 12 weeks (GH: 4.8 vs 1.9 µg/L, p<0.001; IGF-I: 497 vs 265 µg/L, p<0.001), but showed insignificant change at week 24 (GH: 2.3 µg/L; IGF-I: 294 µg/L). Only AcroQoL scores for the psychological appearance subdomain showed a significant increase during the entire 24 weeks (p<0.05). The change in the psychological appearance subdomain of AcroQoL scores demonstrated a significant but weak negative correlation with change in IGF-I levels (r=-0.282, p=0.039). When patients were divided into two groups according to their disease activity at week 24 (controlled vs uncontrolled), there was no difference in AcroQoL scores, but the psychological appearance subdomain of the two groups appeared to change differently over the entire 24-week period (p=0.047). CONCLUSIONS: Medical treatment with octreotide LAR in patients with acromegaly has a limited contribution to HRQoL as assessed by the AcroQoL.

Intraoperative frozen section for the evaluation of extrathyroidal extension in papillary thyroid cancer.

BACKGROUND: We investigated extrathyroidal extension (ETE) through frozen biopsy for intraoperative decision making in patients with papillary thyroid cancer (PTC). METHODS: During the period of the study an operation was performed in 268 patients with PTC and ETE was evaluated using intraoperative frozen biopsies of thyroid tissue. RESULTS: Extrathyroidal extension was confirmed in 54 patients (20 %) on frozen biopsy. Fifty-three patients among 54 patients showing ETE on frozen biopsy were confirmed on permanent pathologic analysis. Accordingly, frozen biopsy had a sensitivity of 66 %, a specificity of 99 %, a positive predictive value of 98 %, and a negative predictive value of 87 %. Tumor size (OR 4.373; CI 2.257-8.475, p = <0.001) was an independent factor for predicting ETE on frozen biopsy. CONCLUSIONS: Intraoperative frozen biopsy can be an useful tool in identifying the presence of ETE. It can also help the operator decide the extent of surgery and central neck dissection in patients with PTC.

FDG PET/CT in the detection of pancreatic metastasis in a patient with follicular thyroid carcinoma and negative I-131 whole body scan findings.

We identified a rare follicular thyroid carcinoma (FTC) metastasis to the pancreas in a patient of FTC. A 65-year-old woman presented at our hospital for evaluation of a pancreatic mass. She had a history of FTC. After total thyroidectomy, I-131 whole body scan showed increased I-131 uptake in the thyroid bed, but there was no evidence of distant metastasis. However, F-18 FDG PET/CT showed a mass with FDG uptake in the pancreatic head. Follow-up PET/CT showed FDG uptake in the pancreatic head and thyroid bed. Pylorus preserving pancreaticoduodenectomy was performed. Histopathological examination supported the diagnosis of metastatic FTC to pancreas.

Ultrasonographic findings relating to lymph node metastasis in single micropapillary thyroid cancer.

BACKGROUND: In thyroid cancer, preoperative ultrasonography (US) is performed to detect the primary tumor and lymph node metastasis (LNM), which are related to prognosis. This study examined the relationships between specific US findings and LNM in micropapillary thyroid cancer (MPTC). METHODS: Data on 220 patients with solitary MPTC who underwent total thyroidectomy and neck dissection between 2008 and 2009 were evaluated retrospectively. We classified the US findings according to the nature, shape, echogenicity, extent, margin, and calcification of the primary tumor and evaluated the correlations between these findings and those of LNM. RESULTS: Hypoechogenicity (odds ratio = 2.331, P = 0.025) and marked hypoechogenicity (OR = 4.032, P = 0.016) of MPTC were risk factors for central LNM. All of the patients with lateral cervical LNM showed hypoechogenicity or marked hypoechogenicity. Hypoechogenicity (odds ratio = 5.349, P = 0.047) and other types of calcification (odds ratio = 2.495, P = 0.010) were significant risk factors for lateral cervical LNM. CONCLUSIONS: Specific sonographic findings (hypoechogenicity or marked hypoechogenicity, and calcification) suggest LNM.

Low serum 25 hydroxyvitamin D is associated with poor clinicopathologic characteristics in female patients with papillary thyroid cancer.

BACKGROUND: Vitamin D has recently attracted attention because reduced levels are associated with the prevalence and aggressiveness of several cancers. This study aimed to evaluate the relationship between preoperative serum 25 hydroxyvitamin D (25(OH) vitamin D) levels and clinicopathologic characteristics in female patients with papillary thyroid cancer (PTC). METHODS: A total of 548 female patients who underwent total thyroidectomy for PTC between June 2012 and May 2013 were included. Blood samples were obtained within two weeks prior to surgery. Patients were categorized into four quartiles by preoperative serum 25(OH) vitamin D levels. The clinicopathologic features of PTC were analyzed retrospectively. RESULTS: Preoperative 25(OH) vitamin D was significantly lower in patients with a tumor size of >1 cm (p = 0.041) or lymph node metastasis (LNM; p = 0.043). No significant trends in several clinicopathologic features were observed in relation to increasing serum vitamin D concentrations except decreasing tumor size (p = 0.010). Patients in the second quartile had a greater occurrence of T stage 3/4 (odds ratio (OR) 2.03 [confidence interval (CI) 1.19-3.44]; p = 0.009), LNM (OR 2.03 [CI 1.19-3.44]; p = 0.009), lateral LNM (OR 5.03 [CI 1.66-15.28]; p = 0.004), and extrathyroidal extension (ETE; OR 1.95 [CI 1.15-3.29]; p = 0.013) than those in the fourth quartile. Multivariate analysis showed that patients in the second quartile had a greater occurrence of T stage 3/4 (OR 1.89 [CI 1.08-3.30]; p = 0.026), LNM (OR 2.04 [CI 1.20-3.47]; p = 0.009), lateral LNM (OR 5.12 [CI 1.68-15.59]; p = 0.004), and ETE (OR 1.81 [CI 1.04-3.15]; p = 0.036) than those in the fourth quartile. When the subjects were recategorized into two groups by median 25(OH) vitamin D levels, those with values below the median had a significantly higher risk of T stage 3/4, LNM, lateral LNM, stage III/IV, and ETE. All values except ETE sustained significance after adjustment. CONCLUSION: Lower preoperative serum 25(OH) vitamin D levels appear to be associated with poor clinicopathologic features in female patients with PTC.

Distant subcutaneous recurrence of a parathyroid carcinoma: abnormal uptakes in the (99m)Tc-sestamibi scan and (18)F-FDG PET/CT imaging.

We report a rare case of distant subcutaneous parathyroid carcinoma recurrence. A 50-year-old woman was referred to our hospital because of sustained hypercalcemia despite surgical removal of a parathyroid carcinoma. A focal uptake in the upper mediastinal area was detected in a (99m)Tc-sestamibi scan, and (18)F-fluorodeoxyglucose (FDG) positron-emission tomography (PET)/computed tomography (CT) imaging demonstrated a subcutaneous mass. She underwent tumor resection, and the pathological findings were consistent with a parathyroid carcinoma. The postoperative serum parathyroid hormone (PTH) level remained within normal limits. However, a new palpable solitary mass was identified in the upper portion of the left breast 1 year postoperatively. Both a (99m)Tc-sestamibi scan and (18)F-FDG PET/CT imaging revealed an abnormal lesion in the upper breast, and subsequent pathology reports confirmed parathyroid carcinoma metastasis. Serum PTH and calcium levels fell within normal ranges after tumor resection. Two subcutaneous recurrent lesions appeared likely due to tumor seeding during the previous endoscopic operation at a local hospital.

Tumor location-dependent skip lateral cervical lymph node metastasis in papillary thyroid cancer.

BACKGROUND: Lateral cervical lymph node metastasis without central lymph node (CLN) metastasis is not infrequent in papillary thyroid cancer (PTC). This study was designed to investigate the frequency and pattern of skip metastasis in PTC. METHODS: We reviewed 131 patients who underwent total thyroidectomy with CLN dissection and selective lymph node dissection. Tumor location was classified in 3 areas (upper, middle, and lower third) based on preoperative ultrasonographic findings. RESULTS: All skip metastases occurred in patients whose tumors had been on the upper part of the thyroid (p < .001). Among 9 patients with skip metastasis, level III lymph nodes (66.7%) were the lymph nodes that were most frequently involved in skip metastasis. CONCLUSION: Primary tumors in the upper portion of the thyroid are closely linked to skip metastasis. Careful preoperative evaluation of lateral cervical lymph nodes is suggested when a tumor is in the upper portion.