Cystic Medullary Thyroid Carcinoma: A Case of Undergoing Endoscopic Thyroid Lobectomy / 대한내분비외과학회지

On ultrasonography, medullary thyroid carcinoma (MTC) shows hypoechogenicity, an irregular margin, a predominantly solid composition, and microcalcifications, similar to those observed in papillary thyroid carcinoma (PTC). MTC presenting as a cystic lesion is rare, and endoscopic thyroidectomy can be performed for benign thyroid masses and early stage PTC, however it is inappropriate for MTC regardless of cystic change. The authors report a case of cystic MTC found after endoscopic thyroid lobectomy and provide a review of the literature on this topic.

Intraoperative neuromonitoring of the external branch of the superior laryngeal nerve during robotic thyroid surgery: a preliminary prospective study

PURPOSE: The aim of this study was to evaluate the feasibility of monitoring external branch of the superior laryngeal nerve (EBSLN) during robotic thyroid surgery. METHODS: A total of 10 patients undergoing bilateral axillo-breast approach (BABA) robotic thyroid surgery were enrolled. The nerve integrity monitor (NIM Response 2.0 System) was used for EBSLN monitoring. We performed voice assessments preoperatively and at 1 and 3 months postoperatively using Voice Handicap Index-10 (VHI-10), maximal phonation time (MPT), phonation efficient index (PEI), and laryngeal electromyography (EMG). RESULTS: A total of 19 EBSLNs were at risk and 14 EBSLNs (73.7%) were identified using neuromonitoring. VHI-10 showed a change of voice over time (0.1 vs. 3.6 vs. 1.3); however, this was not statistically significant. VHI-10 scores normalized at 3 months postoperatively compared to the preoperative scores. MPT (a) (16.0 vs. 15.6 vs. 15.4), and MPT (e) (20.1 vs. 15.4 vs. 18.5) showed no significant differences preoperatively compared to the values obtained 1 and 3 months postoperatively. There was a significant change of PEI over time (4.8 vs. 1.1 vs. 4.6) (P = 0.036); however, the values normalized at 3 months postoperatively. Laryngeal EMG results showed 4 cases (21.2%) of neuropathy of EBSLNs at 1 month postoperatively, and electrodiagnostic studies revealed nearly complete recovery of the function of EBSLNs in 4 patients at 3 months postoperatively CONCLUSION: It is suggested that neuromonitoring of EBSLNs during BABA robotic thyroid surgery is feasible and might be helpful to preserve voice quality.

Clinical Analysis and Proper Management of the Patients Visited ER Due to Ingested Foreign Body: Single Center Experience

PURPOSE: The conventional treatment for ingested foreign bodies (IFB) is removal, which is successful in most cases. However, it can be associated with severe complications, such as gastrointestinal tract perforation, and require emergency surgery. The aim of this study is to analyze clinical data relating to IFB and to develop a proper management plan to reduce the incidence of severe complications. METHODS: Between September 2001 and September 2009, 117 patients visited the emergency room complaining of IFB. Among these patients, 29 were diagnosed with bezoar and were excluded from the study. Medical data for the remaining 88 patients was reviewed retrospectively. For statistical analysis, the foreign bodies (FB) were classified into three subgroups according to their shape (round, sharp, and amorphous). RESULTS: The median age of patients with IFB was seven years, and the male-to-female ratio was 1.3:1. Many of these patients were preschool children under the age of seven who had accidentally sw allowed FB (56 cases, 63.6%). The most common symptom presented among the patients was FB sensation (18 cases, 21%). The results of subgroup analysis showed no significant relation between the shape of the FB and the treatm ent m odality. Spontaneous passage was observed in 21 cases (23.9%). Otherwise, endoscopic removal was performed successfully in 61.4% of cases, and 13 patients required emergency operations (14.8%). CONCLUSION: Early diagnosis and a prompt approach are significant in the successful treatment of IFB. Endoscopic or surgical procedures are sometimes required, particularly in cases where complications are suspected.

The pattern and significance of the calcifications of papillary thyroid microcarcinoma presented in preoperative neck ultrasonography

PURPOSE: To analyze the incidence and patterns of calcification of papillary thyroid microcarcinoma (PTMC) on neck ultrasonography (NUS) and assess the clinical implications of calcification, especially for neck node metastasis. METHODS: The clinical data of 379 patients with PTMC who underwent thyroidectomy between January and December 2011 were retrospectively analyzed. PTMC lesions were classified into four subgroups according to their calcification patterns on preoperative NUS: microcalcification, macrocalcification, rim calcification, and noncalcification. The clinicopathologic characteristics were compared between the patients with and without calcification, and among the four subgroups. RESULTS: Calcifications were detected on NUS in 203 patients (53.5%) and central neck node metastasis was observed in 119 patients (31.3%). Calcification was associated with larger tumor size (0.68 cm vs. 0.54 cm), higher rate of lymph node metastasis (38.6% vs. 23.2%) and higher lymph node ratio (0.11 vs. 0.06) compared to noncalcification (All P < 0.05). In addition, the extent of calcification correlated with lesion size (0.67 cm vs. 0.69 cm vs. 0.85 cm). Further, the likelihood of lymph node metastasis also correlated with the extent of calcification in the order of non-, micro- and macrocalcification (23.3%, 36.8%, and 44.1%, respectively). The calcification rate was higher in patients with lymph node metastasis than those without it (65.5% vs.47.7%) (All P < 0.05). CONCLUSION: PTMC patients positive for calcification on NUS had a higher rate of lymph node metastasis, and a higher lymph node ratio compared to noncalcification patients. Calcification patterns should be assessed carefully in patients with PTMC by preoperative NUS.

The prognosis and treatment of primary thyroid cancer occurred in breast cancer patients: comparison with ordinary thyroid cancer

PURPOSE: Due to the increased prevalence of thyroid cancer, it has been frequently detected in breast cancer patients recently. The aim of this study was to evaluate the clinicopathologic characteristics of thyroid cancer in breast cancer patients with respect to prognosis and treatment. METHODS: From August 1998 to September 2012, 101 breast cancer patients were diagnosed with thyroid cancer (BT group). One hundred ninety-three female patients with a thyroid malignancy that underwent thyroidectomy in 2008 were recruited as controls (oT group). The clinicopathologic results of these two groups were compared. RESULTS: Patients were older (51.40 vs. 47.16, P < 0.001), mean tumor size was smaller (0.96 cm vs. 1.43 cm, P < 0.001), and extrathyroidal extension was less common in the BT group. In both groups, papillary thyroid carcinoma was the most common type of thyroid malignancy. T and N classifications of thyroid cancer were less severe in the BT group, but group TNM stages were similar. Endoscopic thyroid surgery was performed in 12.9% of patients in the BT group and in 6.7% of patients in the oT group. Postoperative radioactive iodine ablation was performed less often in the BT group (P < 0.001). Group recurrence rates were not significantly different. CONCLUSION: Thyroid cancer in breast cancer patients was diagnosed at earlier status than ordinary thyroid cancer. However, the prognosis of thyroid cancer in breast cancer patients was not superior to that in patients with thyroid cancer alone. Radioactive iodine ablation was performed less often and endoscopic surgery could be performed in breast cancer patients.

Clinical Characteristics for Early Recovery from Temporary Hypoparathyroidism in Patients Undergoing Total Thyroidectomy / 대한내분비외과학회지

PURPOSE: Several reports have examined the predictors of temporary hypoparathyroidism after total thyroidectomy; however, few have assessed the clinical predictors of early recovery from the condition. Here, we compared the clinical factors of early and late recovery groups of patients with temporary hypoparathyroidism. METHODS: The electronic medical records of 248 patients who underwent total thyroidectomy from January 2012 to July 2013 and had parathyroid hormone (PTH) levels <10 pg/mL on the first postoperative day were examined retrospectively. The early recovery group showed recovery from PTH at two weeks postoperatively and the late recovery group showed recovery from PTH at one month postoperatively. RESULTS: The early recovery group included a lower proportion of males (8.6% vs. 23.7%, P<0.01) and a higher proportion of patients with more than three parathyroid glands saved (83.8% vs. 76.8%, P<0.04). There were no significant differences in the other variables examined. CONCLUSION: The early recovery group of patients with temporary hypoparathyroidism included a lower proportion of males and a higher proportion of patients with more than three parathyroid glands saved intraoperatively. These findings can be used as clinical indicators when discharge medication is prescribed.

Comparative Analysis of Three Lobectomy Methods for Papillary Thyroid Cancer / 대한내분비외과학회지

PURPOSE: The current study examined the validity and outcomes of three lobectomy methods for papillary thyroid carcinoma (PTC), open surgery, minimally invasive videoassisted thyroidectomy (MIVAT), and endoscopic surgery. METHODS: Between January 2006 and June 2011, 360 patients underwent lobectomy for treatment of PTC. Clinical data were collected and analyzed retrospectively. Open lobectomy, MIVAT, and endoscopic lobectomy were performed in 170 (47.2%, Group A), 81 (22.5%, Group B), and 109 patients (30.3%, Group C), respectively. Median tumor size was 0.5 cm. RESULTS: No significant differences in tumor size, lymphovascular invasion, extrathyroidal extension, and metastatic lymph node number were observed among the groups. However, the mean number of retrieved central lymph nodes was higher in the open surgery group than in the other groups (8.9, 4.9, and 5.8 in Groups A, B, and C, respectively P<0.05). Postoperative bleeding occurred in one patient each in Group A. Temporary hypoparathyroidism developed in ten, three, and three patients in Groups A, B, and C, respectively. Recurrence occurred in five cases (1.4%), however, no significant difference in short-term recurrence (median duration of follow up: 1,109 days) was observed among the three groups. CONCLUSION: The number of retrieved central lymph nodes was higher in the open surgery group. However, no differences in the incidence of complications or short-term recurrence were observed among the groups, indicating that either one of these methods can be recommended as limited surgery for PTC.

Assessment of Postoperative Scar Using Modified Vancouver Scar Scale of 283 Patients Who Underwent Open Thyroidectomy in a Single Institution / 대한내분비외과학회지

PURPOSE: The postoperative scar of open thyroidectomy is one of the clinical issues in patients diagnosed with thyroid disease. The aim of this study was to analyze postoperative scars in patients who underwent thyroidectomy based on the Modified Vancouver Scar Scale and to find factors for use in predicting formation of hypertrophied scars and keloids. METHODS: Clinical data from 283 patients who underwent thyroidectomy were collected randomly and analyzed retrospectively. All postoperative scars were classified according to five categories; excellent, good, moderate, hypertrophied, and keloid, using the Modified Vancouver Scar Scale according to the assessment of pliability, height of the scar, vascularity, and pigmentation. For analysis, hypertrophied and keloid were classified as bad status and others were classified as good status. RESULTS: According to our results, 84.8% of scars were classified as good status and 15.2% of scars were classified as bad status. Forty percent of patients who were in their twenties, 17.8% of patients who were in their thirties, and 22.1% of patients who were in their forties showed bad status; 92.9% of patients who were in their fifties and 89.2% of patients who were in their sixties showed good status (P=0.003). The only statistically significant factor influencing the scar status was the weight of the thyroid (P=0.022). CONCLUSION: Postoperative scars from thyroid surgery were evaluated using the Modified Vancouver Scar Scale. Age was the most important factor in formation of hypertrophied and keloid scar and the weight of the excised thyroid also influenced the scar status. Preoperative prediction of the status of the scar might be possible considering the age and size of the thyroid gland.

The Utility of Clinical Findings Including Serum TSH and Neck Ultrasonography for Predicting Thyroid Malignancy in Atypia of Undetermined Significance/Follicular Lesions of Undetermined Significance / 대한내분비외과학회지

PURPOSE: Neck ultrasonography (NUS) is one of the most commonly used methods for evaluating thyroid nodules and preoperative higher TSH levels are known to be associated with differentiated thyroid cancers. This study was conducted to assess whether serum TSH levels and neck ultrasonography are of value in predicting malignancy in patients with atypia of undetermined significance/follicular lesions of undetermined significance (AUS). METHODS: A total of 62 patients (7 men, 55 women; mean age 48.4±11.9 years) who had indeterminate cytologic results indicating AUS underwent thyroidectomy. Preoperative clinical data including serum TSH and the findings of NUS were analyzed retrospectively between malignant and non-malignant groups. RESULTS: The final pathologic results of malignancy were reported in 53 of 62 (85.5%) patients with AUS. There was no significant difference in the mean value of preoperative serum TSH between malignant and non-malignant groups (1.5±1.3 vs. 1.9±1.2, P=NS). In NUS, the patients diagnosed with malignancy in histology showed a higher proportion of calcification, taller-than-wide shape, hypoechoic texture and irregular margin (58.5% vs. 22.2%, P=0.044; 34% vs. 0%, P=0.038; 98.1% vs. 44.4%, P<0.01; 47.2% vs. 0%, P=0.008). CONCLUSION: Serum TSH was not related to malignancy in thyroid nodules showing AUS. However, ultrasonographic features including calcifications, taller-than-wide shape, hypoechoic pattern and irregular margin could be used to predict malignancy. Ultrasonography should be the first useful methods when making decisions regarding management of thyroid nodules showing indeterminate cytologic results as AUS.

Significance of Surgical Treatment for Toxic Thyroid Nodule / 대한내분비외과학회지

PURPOSE: Autonomous hyperfunctioning thyroid nodules produce thyroid hormone independently of TSH. Of these, toxic thyroid nodules provoke hyperthyroidism and can be treated by surgery or radioactive iodine therapy. The aim of this study was evaluating the role of each treatment method in Korean patients with toxic thyroid nodule. METHODS: From July 2008 to June 2013, 10 patients were diagnosed with toxic thyroid nodule. We diagnosed toxic thyroid nodule by thyroid function test and thyroid scan. Thyroid function test showed hyperthyroidism. Hot nodule and suppressed uptake surrounding thyroid tissue was observed on thyroid scan. We analyzed medical records of 10 patients retrospectively. RESULTS: 9 patients were women and 1 patient was man. Median follow-up duration was 22 months. Most common symptom was neck mass (80%) and the median tumor size was 2.66 cm. 99mTc uptake increased by 6.41% on thyroid scan. All 10 patients refused radioactive iodine therapy and 3 of these denied even operation. In 7 patients underwent thyroidectomy, 4 patients were proved having thyroid malignancy (3 papillary thyroid carcinomas and 1 follicular thyroid carcinoma). CONCLUSION: In Korean patients, toxic thyroid nodule was likely to accompany thyroid malignancy and radioactive iodine therapy is contraindicated in this case. Therefore, we suggested that surgery has to be considered in the first place in treatment of toxic thyroid nodule.

Analysis of patients with anaplastic thyroid cancer expected to have curative surgery / 대한외과학회지

PURPOSE: Anaplastic thyroid cancer (ATC) is rare and has a poor prognosis. The aim of this study was to analyze the clinicopathologic characteristics of patients diagnosed with ATC expected to undergo curative thyroidectomy, with the goal of finding differences between patients surviving > or =6 months and or =6 months after operation. In patients surviving > or =6 months, all lesions were 5 cm, and two of the five patients underwent less than total thyroidectomy (P = 0.287 and 0.152, respectively). All patients with lesion size <5 cm underwent total thyroidectomy and showed a shorter median operation time (P = 0.182 and 0.033, respectively). CONCLUSION: ATC showed female predominance. Patients initially presented with neck mass, and median age was 55 years. In patients with ATC who are expected to undergo curative thyroidectomy, surgery should actively be considered as primary therapy for patient survival when the size is <5 cm.

Level V Lymph Node Dissection in PTMC Patients: Is This Necessary? / 대한내분비외과학회지

PURPOSE: Cervical lymphadenectomy is frequently performed in papillary thyroid carcinoma (PTC) patients with lateral node metastasis to improve regional control, but the cervical levels that require dissection remain controversial. We conducted this study to investigate the necessity of the routine dissection of level V in papillary thyroid microcarcinoma (PTMC). METHODS: To identify the relation between PTMC and level V metastases, we analyzed 90 patients who underwent lateral neck dissection (ND). Twenty-five patients underwent lateral ND when metastasis was detected during follow-up, whereas the other 65 patients underwent total thyroidectomy with central and lateral ND at initial surgery. RESULTS: There were 18 PTMC patients and 72 patients with a PTC of >1 cm. Metastasis at level III or IV was detected in 80.0% and 78.9%, respectively, whereas metastasis at level V was only detected in 12.2%, and metastasis at level II occurred in 30%. In PTMC patients, metastatic rates at levels II, III, IV, and V were 11.1%, 61.1%, 61.1%, and 5.6%, respectively, and in patients with a PTC of >1 cm, metastatic rates at levels II, III, IV, and V were 34.7%, 84.7%, 83.3% and 13.9%, respectively. PTMC was not found to be significantly associated with level V metastasis (P=0.452). CONCLUSION: The level V metastatic rate in PTMC was no different from that of PTC>1 cm statistically. However, the metastatic rate was only 5.6% in PTMC. Therefore, we recommend that care be taken when deciding whether to perform level V dissection when dissecting the lateral cervical nodes in PTMC.

An exclusively dopamine secreting paraganglioma in the retroperitoneum: a first clinical case in Korea / 대한외과학회지

Exclusively dopamine producing retroperitoneal paragangliomas are extremely rare. We have experienced the first Korean case managed successfully based on the proper evaluation. A 26-year-old female patient came to our attention after the accidental detection of an adrenal mass. She had no symptoms and denied any family history. Laboratory evaluations were normal but serum dopamine (425 ng/L) and 24-hour urine dopamine levels (1,565.3 microg/day) were elevated. She underwent laparoscopic right adrenalectomy. Histopathological diagnosis was a paraganglioma. After operation, dopamine levels in serum and 24-hour urine dropped to 0.09 ng/L and 388.4 microg/day. Dopamine producing paraganglioma elicit no clinical symptoms. Only the dopamine level is elevated in serum and 24-hour urine samples. Surgical resection without using preoperative alpha blockage is the treatment of choice. The prognosis for patients with this tumor tends to be poor because the diagnosis is usually delayed due to lack of symptoms.

Comparative Study of Postoperative Complications of High Ligation and Stripping with Endovenous Laser Treatment for Varicose Veins

PURPOSE: Endovenous laser treatment (EVLT) has been performed as a minimally invasive alternative to conventional surgery for saphenous vein incompetence. It is thought to minimize postoperative complications and improve the quality of life compared with high ligation and stripping. The aim of this retrospective study was to compare the postoperative complications and quality of life of EVLT with high ligation and stripping (HS). METHODS: A total of 294 patients with 390 saphenous veins were included in this study. Patients with saphenous vein incompetence were treated with either HS (n=98; HS group) or EVLT (n=196; EVLT group). Patients were evaluated preoperatively and at 1, 3 months, postoperatively. Postoperative complications, the Venous Clinical Severity Score (VCSS) and the Aberdeen Varicose Vein Symptom Severity Score (AVSS) were compared between the two groups. RESULTS: The total postoperative complication rate was 31.62%, in HS and 27.47% in the EVLT groups. Most of the complications were minor and self-limited. There were no statistical differences in the total complication rate and the occurrence of complications such as hematoma, paresthesia and phlebitis. Pain was less severe following EVLT compared to HS. The EVLT patients were discharged and resumed their normal activity earlier than the HS patients. The two groups had similar improvement of the VCSS and AVSS at 1 and 3 months, postoperatively. CONCLUSION: With the similar, comparable short-term safety outcome, both HS and EVLT may be considered as safe procedures for the treatment of varicose veins. Long-term, large population-based randomized studies with promising data for the improvement of quality of life scores will be needed for the evaluation of EVLT before it becomes a standard treatment for saphenous vein incompetence.