Can Suspicious Ultrasound Features Predict BRAFV600E Status in Papillary Thyroid Cancer?

BACKGROUND: Papillary thyroid carcinoma (PTC) can be predicted from certain suspicious ultrasound (US) features of thyroid nodules. The aim of this study was to examine if these suspicious features can predict the more aggressive PTC associated with B-type Raf kinase (BRAFV600E) mutation. METHODS: This was a retrospective review of prospectively collected data on patients with PTC and known BRAFV600E status. All patients underwent preoperative US by the same surgeon who performed all the operations. We divided patients into BRAFV600E positive and negative groups. All ultrasonographic data were collected including nodule size, echogenicity, solid or cystic nature, presence of calcifications, irregular margins, and internal vascularity. RESULTS: Of 141 patients with PTC, BRAFV600E mutation was detected in 48 (34.0$) patients. There was no significant difference in nodule size (2.06 cm ± 1.37 vs. 2.15 cm ±1.55, p = 0.75) between BRAFV600E positive and negative groups. BRAFV600E positivity was associated with higher rates of -hypoechogenicity (57.5$ vs. 36.6, p = 0.02), calcifications (48.9 vs. 19.4$, p < 0.01), and irregular margins (21.3 vs. 6.5$, p < 0.01). There was no significant difference in the noncystic nature or internal vascularity between BRAFV600E positive and negative groups. The presence of all suspicious US features is associated with a positive predictive value of 100.0$. In the absence of all suspicious features, the negative predictive value was 84.2$. When suspicious lymph nodes (LNs) detected by preoperative US were compared, there was no significant difference between BRAFV600E positive and negative groups (30.6 vs. 21.7$, p = 0.35). CONCLUSION: The presence of multiple suspicious US findings of thyroid nodules can predict the BRAFV600E mutation status of papillary thyroid cancer nodules. The highest accuracy overall (93.2$) was achieved by combining calcification, irregular margins, and hypoechogenicity with extrathyroidal extension and LN metastasis. Future multi-institutional studies are warranted to help surgeons with risk stratification and operative planning for patients with papillary thyroid cancer.

Well-differentiated thyroid cancer and robotic transaxillary surgery at a North American institution.

BACKGROUND: Recent studies from Asia have reported the safety and feasibility of robotic-assisted thyroid surgery. In the United States, several small series and case reports have been published, mostly regarding treatment of benign disease. The aim of our study is to report the safety and feasibility of robotic surgery for well-differentiated thyroid cancer patients at a North American institution. MATERIALS AND METHODS: We performed a retrospective cohort study using a prospectively collected single-center clinical database at Tulane University Medical Center. We included all well-differentiated thyroid cancer patients who underwent robotic-assisted or conventional cervical approach thyroid surgery with or without lymph node dissections at our institution from January 2015 to June 2017. Patient demographics and perioperative data were collected and analyzed. RESULTS: A total of 144 surgeries for thyroid cancer were performed; 35 (24.3%) were robotic-assisted. There were no significant differences in estimated blood loss, operative times, complication rates, specimen sizes, positive microscopic margins, number of lymph nodes removed with associated lymph node dissections, patient follow-up duration, or clinical recurrence rates between the two groups. Overall length of stay was shorter for robotic-assisted surgery, at 0.6 ± 0.9 d, versus 1.1 ± 1.2 d for conventional open surgery (P = 0.009). For robotic-assisted surgery, 19 patients (54.3%) were discharged on the day of procedure, and only one patient was admitted as inpatient to the hospital (2.9%). CONCLUSIONS: Robot-assisted thyroid surgery is a safe, feasible, and oncologically sound approach for a select group of well-differentiated thyroid cancer patients. However, long-term studies are needed.

Continuous vagal monitoring value in prevention of vocal cord paralysis following thyroid surgery.

OBJECTIVES/HYPOTHESIS: Continuous intraoperative neuromonitoring (CIONM) of the vagus nerve was proposed to obtained frequent repetitive electromyography (EMG) data to recognize early change in intraoperative function of the recurrent laryngeal nerve. We examine our initial experience using this technology. STUDY DESIGN: Retrospective review. METHODS: Data for all patients who underwent neck surgery by a single surgeon at a North American institution over a 5-year period were reviewed. CIONM was used in cases with possible higher risk of traction injury and according to surgeon preference. In these cases, stretch injury was established by warning alarm with threshold of ≥50% reduction in amplitude and/or ≥ 10% increase in latency. Preoperative and postoperative direct laryngoscopy was performed for all patients. RESULTS: A total of 879 endocrine neck surgeries were performed. CIONM was used to monitor 455 recurrent laryngeal nerves (RLNs) in 344 (39.1%) surgeries. An automatic periodic stimulation (APS) alarm detected impending nerve injury in 33 (9.6%) cases by 64.9% ± 12.7% decrease in amplitude and by 27.3% increase in latency in one case. A total loss of signal (LOS) was detected in 15 (4.36%) cases. The immediate release of causative retraction successfully preserved the nerves in all cases with impending injury; however, there was no improvement in the LOS cases. Other than the cases with LOS, postoperative laryngoscopy showed normal vocal cord function in all cases. CONCLUSIONS: APS technology is safe, feasible, and helpful in approximately 10% of cases in our series, which developed nascent neurapraxia adverse EMG changes associated with intraoperative RLN stretch that could be reversed intraoperatively. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2429-2432, 2018.

Concomitant thyroid disease and primary hyperparathyroidism in patients undergoing parathyroidectomy or thyroidectomy.

BACKGROUND: Thyroid abnormalities have been found intraoperatively during parathyroidectomy and have resulted in concomitant thyroidectomy. The identification of concomitant disease is important prior to primary operation in order to minimize reoperations. This study investigates the incidence of concomitant primary hyperparathyroidism (PHPT) and thyroid nodular disease in patients undergoing thyroidectomy or parathyroidectomy. METHODS: We performed a retrospective review of prospectively gathered data for 621 patients who underwent thyroidectomy, parathyroidectomy, or both at Tulane Medical Center. Information obtained included initial referral, initial thyroid stimulating hormone (TSH), initial parathyroid hormone (PTH), fine needle aspiration (FNA) results, ultrasound results, type of operation performed, final diagnosis, and final pathology. RESULTS: Among the 400 patients referred primarily for thyroid disease, 13.50% underwent a thyroidectomy and parathyroidectomy (PTX) simultaneously and 10.75% received a final diagnosis of thyroid and concomitant parathyroid disease. Among the 103 patients referred primarily for parathyroid disease, 26.21% underwent a PTX and thyroidectomy and 24.27% received a final diagnosis of both thyroid and parathyroid disease. Patients referred primarily for parathyroid disease were more likely to receive a final diagnosis of both parathyroid and thyroid disease and were more likely to undergo a combined operation. CONCLUSIONS: Concomitant thyroid and parathyroid disease occur and preoperative analysis is important to avoid increased complications from reoperations.

Robotic transaxillary parathyroidectomy.

We recently reported on the safety and feasibility of robotic transaxillary approaches for parathyroid surgeries with benefit of avoiding a visible cervical scar. Herein, we demonstrate our technique with utilization of intraoperative nerve monitoring and indocyanine green (ICG) imaging. The patient was discharged a few hours after the surgery.

Gasless trans-axillary robotic thyroidectomy: the technique and evidence.

Robot assisted thyroid surgery has the advantage of a superior field vision and technical advancements of robotic technology that have permitted novel remote access thyroid surgical approaches. Gasless trans-axillary robot-assisted thyroidectomy has been proved to be among the most current feasible approaches. This approach offers an excellent cosmetic outcome, with comparable outcomes to conventional surgical approaches. This review aims to provide details of this specific remote access technique for thyroid resection with most recent evidences in the literature.

Robotic and endoscopic transoral thyroidectomy: feasibility and description of the technique in the cadaveric model.

BACKGROUND: Numerous new approaches have been described over the years to improve the cosmetic outcomes of thyroid surgery. Transoral approach is a new technique that aims to achieve superior cosmetic outcomes by concealing the incision in the oral cavity. METHODS: Transoral thyroidectomy through vestibular approach was performed in two institutions on cadaveric models. Procedure was performed endoscopically in one institution, while the robotic technique was utilized at the other. RESULTS: Transoral thyroidectomy was successfully performed at both institutions with robotic and endoscopic techniques. All vital structures were identified and preserved. CONCLUSIONS: Transoral thyroidectomy has been performed in animal and cadaveric models, as well as in some clinical studies. Our initial experience indicates the feasibility of this approach. More clinical studies are required to elucidate its full utility.