Serum Adiponectin and Progranulin Level in Patients with Benign Thyroid Nodule or Papillary Thyroid Cancer

Background@#Obesity is associated with thyroid cancer risk. Adiponectin has insulin-sensitizing and anti-inflammatory effects, while progranulin is associated with inflammation and tumorigenesis. We investigated serum adiponectin and progranulin levels in patients with benign thyroid nodule (benign group) and papillary thyroid cancer (PTC; PTC group). The associations between these levels and the clinicopathological features of PTC were evaluated. @*Methods@#We included 157 patients who underwent thyroid surgery (17% of benign and 83% of PTC group). Clinicopathological features including size, lymph node metastasis, extrathyroidal extension (ETE), multifocality, American Thyroid Association risk stratification were evaluated. @*Results@#The age was 42.0 years, and 69% were female. Serum adiponectin and progranulin levels were 6.3 μg/mL and 101.5 ng/mL in the benign group and 5.4 μg/mL and 106.1 ng/mL in the PTC group, respectively (P=0.6 and P=0.4, respectively). Serum adiponectin levels showed no significant differences according to clinicopathological features of PTC. The proportions of patients with primary tumor size >1 cm were 3%, 5%, 8%, and 8% according to serum progranulin level quartiles, respectively (P=0.03). The proportions of patients with microscopic/gross ETE were 8%/0%, 9%/1%, 11%/1%, and 11%/2% according to serum progranulin level quartiles, respectively. Median serum progranulin level was significantly higher in patients with PTC >1 cm than in patients with papillary thyroid microcarcinoma (P=0.04, 115.3 ng/mL and 104.7 ng/mL, respectively). @*Conclusion@#Serum adiponectin and progranulin levels showed no significant difference between benign and PTC groups. Increased serum progranulin levels were significantly associated with PTC >1 cm and microscopic and gross ETE.

Different prognostic values of individual hematologic parameters in papillary thyroid cancer due to age-related changes in immunity

PURPOSE: Several studies have reported the plausible association of neutrophil-to-lymphocyte ratio (NLR) with the prognosis of papillary thyroid cancer (PTC), but the results are inconsistent. In PTC, chronic inflammation is closely related to tumor progression, and the age of the patient has a great influence on prognosis. Therefore, considering the changes in the immune system with aging, we classified the patients according to age and assessed the prognostic value of individual hematologic parameters. METHODS: This retrospective analysis included 1,921 patients who underwent thyroidectomy for PTC. Patients were divided into 2 groups based on their age: Y-group (age < 45) and O-group (age ≥ 45). Blood counts were measured within 14 days before surgery. RESULTS: The Y-group consisted of 914 patients aged < 45 years and the O-group consisted of 932 patients aged ≥ 45. In both groups, the common prognostic factors related to disease recurrence were only 6 or more metastatic lymph node and grossly extrathyroidal extension, and hematologic parameters were different between the 2 groups. High Platelet-lymphocyte ratio (PLR) in the Y-group and high NLR in the O-group were identified as independent predictors of disease recurrence (NLR: hazard ratio [HR], 3.28; 95% confidence interval [CI], 1.23–8.73; P = 0.018; PLR: HR, 3.08; 95% CI, 1.26–7.52; P = 0.014). CONCLUSION: The results suggest that changes in immunity with aging may affect prognosis in patients with PTC, and thus hematologic parameters might be employed as prognostic markers depending on the age of the patients.

Diagnostic Value of Contrast-Enhanced Digital Mammography versus Contrast-Enhanced Magnetic Resonance Imaging for the Preoperative Evaluation of Breast Cancer / 한국유방암학회지

PURPOSE: This study aimed to compare the diagnostic performance of contrast-enhanced digital mammography (CEDM) and contrast-enhanced magnetic resonance imaging (CEMRI) in preoperative evaluations, and to evaluate the effect of each modality on the surgical management of women with breast cancer. METHODS: This single-center, prospective study was approved by the Institutional Review Board, and informed consent was obtained from all patients. From November 2016 to October 2017, 84 patients who were diagnosed with invasive carcinoma (69/84) and ductal carcinoma in situ (15/84), and underwent both CEDM and CEMRI, were enrolled. Imaging findings and surgical management were correlated with pathological results and compared. The diagnostic performance of both modalities in the detection of index and secondary cancers (multifocality and multicentricity), and occult cancer in the contralateral breast, was compared. The authors also evaluated whether CEDM or CEMRI resulted in changes in the surgical management of the affected breast due to imaging-detected findings. RESULTS: Eighty-four women were included in the analysis. Compared with CEMRI, CEDM demonstrated a similar sensitivity (92.9% [78/84] vs. 95.2% [80/84]) in detecting index cancer (p=0.563). For the detection of secondary cancers in the ipsilateral breast and occult cancer in the contralateral breast, no significant differences were found between CEDM and CEMRI (p=0.999 and p=0.999, respectively). Regarding changes in surgical management, CEDM resulted in similar changes compared with CEMRI (30.9% [26/84] vs. 29.7% [25/84], p=0.610). Regarding changes in surgical management due to false-positive findings, no significant differences were found between CEDM and CEMRI (34.6% [9/26] vs. 44.0% [11/25], p=0.782). CONCLUSION: CEDM demonstrated a diagnostic performance comparable with CEMRI in depicting index cancers, secondary cancers, and occult cancer in the contralateral breast. CEDM demonstrated similar changes in surgical management compared with CEMRI.

A comparison of postoperative pain after conventional open thyroidectomy and single-incision, gasless, endoscopic transaxillary thyroidectomy: a single institute prospective study

PURPOSE: The aim of this study was to compare postoperative pain between single-incision, gasless, endoscopic transaxillary thyroidectomy (SET), and conventional open thyroidectomy. METHODS: From March to December 2015, patients with thyroid disease underwent total thyroidectomy or lobectomy. Patient's clinical and pathological characteristics, postoperative pain score using visual analog scale (VAS) were compared between the 2 groups. The primary endpoint was postoperative pain evaluated by VAS score and postoperative analgesic use. Operation time and length of postoperative hospital stay were secondary outcome measures. RESULTS: Conventional, open cervical surgery was performed on 30 patients (group O) and SET was performed on 27 patients (group E). Pain scores in shoulder area, which is the ipsilateral side of the tumor location at 1 hour and 24 hours after surgery, were higher in group E patients (P < 0.05). Pain scores 7 days after surgery did not differ between the 2 groups according to the locations (P < 0.05). CONCLUSION: In conclusion, endocrine surgeons should be concerned about immediate higher postoperative pain scores in patients who undergo SET.

Risk factors associated with high thyroglobulin level following radioactive iodine ablation, measured 12 months after treatment for papillary thyroid carcinoma

PURPOSE: The measurement of serum thyroglobulin (Tg) of papillary thyroid carcinoma patients, 12 months after total thyroidectomy and radioactive iodine (RAI) ablation following thyroxine hormone withdrawal (T4-off Tg) or recombinant human thyroid-stimulating hormone stimulation (rhTSH-Tg), is standard method for monitoring disease status. The aim of this study was to find predictive factors for detectable T4-off Tg during follow-up. METHODS: A retrospective review was conducted of 329 patients who underwent total thyroidectomy and RAI ablation between October 2008 and August 2012. Subjects were assigned to high (>1 ng/mL, n = 53) and low (≤1 ng/mL, n = 276) groups, based on T4-off Tg measured 12 months postoperatively. Demographic and clinicopathological characteristics at diagnosis and follow-up were compared between the 2 groups. RESULTS: The low and high T4-off Tg groups differed with respect to tumor size, preoperative Tg, ablative Tg, cervical lymph node metastasis, thyroglobulinemia out of proportion to results of diagnostic whole body scan, and American Thyroid Association 3-level stratification and restratification. Multivariate analysis confirmed that ablative Tg > 1.0 ng/mL (odds ratio [OR], 10.801; P = 0.001), more than 5 cervical lymph node metastasis (OR, 6.491; P = 0.003), and thyroglobulinemia out of proportion (OR, 9.221; P = 0.000) were risk factors. CONCLUSION: Ablative Tg >1.0 ng/mL, more than 5 cervical lymph node metastasis, and thyroglobulinemia out of proportion were independent factors for T4-off Tg >1 ng/mL 12 months postoperative. In low-risk patients without these risk factors, the possible omission of Tg measurements could be considered during follow-up.

Assessing cosmetic results after conventional thyroidectomy using the EASY-EYE_C: a double-blind randomized controlled trial

PURPOSE: The incidence of thyroid cancer is relatively high, especially in young women, and postoperative scarring after thyroidectomy is an important problem for both patients and clinicians. Currently, there is no available product that can be used for wound protection during thyroid surgery. We used the EASY-EYE_C, a new silicone-based wound protector. METHODS: We conducted a double-blind randomized controlled trial to assess the efficacy of the EASY-EYE_C with surgical scars. We studied 66 patients who underwent conventional total thyroidectomy or hemithyroidectomy performed by a single surgeon from August 2015 to June 2016. At 6-week follow-up, a single blinded physician observed the wounds to make clinical assessments using the Patient and Observer Scar Assessment Scale (POSAS), the Vancouver Scar Scale (VSS), and a modified Stony Brook Scar Evaluation Scale (SBSES). RESULTS: There were no significant differences by sex, age, type of surgery, body mass index, length of wound, incision site (from sternal notch), or thyroid weight, but the duration of operation was significantly shorter in the experimental group (E group). The e-group also had better POSAS scores than the control group (C group), with means of 43.2 (standard deviation [SD], ±15.9) versus 68.3 (SD, ±21.5), respectively (P < 0.05). The modified SBSES and VSS scores were similar to those from the POSAS. CONCLUSION: In this study, all scores for evaluating outcomes were higher in the E group than in the C group. In addition, the operation time was significantly shorter in the E group. Therefore, the EASY-EYE_C may be useful for improving the cosmetic outcomes of conventional thyroid surgery.

Surgical Treatment Guidelines for Patients with Differentiated Thyroid Cancer: The Korean Association of Thyroid and Endocrine Surgeons (KATES) Guidelines Taskforce / 대한내분비외과학회지

No abstract available.

Factors That Influence TSH Levels after Thyrogen Injection before RAI Therapy / 대한내분비외과학회지

PURPOSE: Radioactive iodine therapy was used for detection and destruction of remnant normal of malignant thyroid tissue after thyroidectomy for differentiated thyroid gland cancer. To achieve a high level of TSH, discontinuation of levothyroxine is required. Discontinuation of L-T4 causes hypothyroidism, serious adverse impacts on patients, therefore, rhTSH is used. The aim of this study was to evaluate the factors influencing serum peak TSH levels after administration of rhTSH in patients with thyroid papillary carcinoma. METHODS: Retrospective review was conducted of 249 patients who underwent total thyroidectomy and subsequent RAI therapy at Kangbuk Samsung Hospital between October 2008 and February 2014. We divided patients into two groups according to the stimulated serum TSH level after administration of rhTSH (Group 1: TSH or =30). Clinicopathological characteristics were compared between the two groups. RESULTS: Serum peak TSH was negatively related to height, weight, BSA, and BMI, and positively related to LBM. A non-significant negative correlation was found between serum peak TSH and body composition. CONCLUSION: Patients' weight, height, BMI, BSA, and LBM were not associated with serum peak TSH after rhTSH administration. More pharmakokinetic study of rhTSH is needed in order to find correlation between pharmacokinetic factors and TSH level.

Initial Experience of Single Port Transperitoneal Laparoscopic Adrenalectomy / 대한내분비외과학회지

PURPOSE: Single port laparoscopic surgery is an area of active investigation in abdominal surgery. A standard procedure for single port laparoscopic adrenal surgery has not been established. We retrospectively investigated intraoperative and postoperative outcomes following laparoscopic adrenalectomy via mono-port (LAMP). METHODS: Between March 2009 and December 2009, 10 patients underwent LAMP at Kangbuk Samsung Hospital. The same surgeon performed all surgeries. The first 5 cases underwent LAMP using an Alexis Wound Retractor (Applied Medical, Rancho Santa Margarita, CA, USA) with surgical gloves, and others were done with an OCTO Port (Dalim Surgnet, Korea). RESULTS: Of the 10 patients, 5 were male and 5 were female. The mean age was 43.7±9.9 years (range, 34~62), and the mean BMI was 24.1±4.0 kg/m² (Range, 17.1 ~30.0). The mean tumor size was 32.5±16.9 mm (range, 12~60),mean operative time was 127.0±29.5 min (range, 90~180), and mean hospital stay was 4.5 days (range, 3~7). Three patients were diagnosed with non-functioning cortical adenoma, 3 with Cushing's syndrome, 2 patients with pheochromocytoma, and others with primarily hyperaldosteronism and myelolipoma. Major postoperative morbidity, blood transfusions, or conversion to open surgery did not occur. CONCLUSION: The outcome of LAMP demonstrates the safety and feasibility of this procedure. With increasing surgeon experience and refinement in instrument technology, we believe LAMP is likely to become a standard approach to adrenal disease.

10 Year-Experience of Endoscopic Thyroidectomy for Papillary Thyroid Microcarcinoma in Single Institution: Breast Approach and Gasless Transaxillary Approach

PURPOSE: Endoscopic thyroid surgery has been widely used because of the cosmetic advantage and the development of laparoscopic instruments. We have performed endoscopic thyroidectomy by breast approach and gasless transaxillary approach on papillary thyroid microcarcinomas. In this study, we describe these two types of endoscopic procedures with the technique of the method and surgical outcomes. METHODS: From Oct. 1999 to Oct. 2009, each procedure was performed in 162 patients divided into two groups. Breast approach group was in 91 patients and gasless transaxillary approach group was in 71 patients. We compared the results of mean ages, sex ratio, extent of operation, mean hospital stay, operating time, pathologic characteristics and postoperative complications between the breast approach group and gasless transaxillary approach group. RESULTS: Ninety-one cases treated using breast approach, and seventy-one cases treated using gasless transaxillary approach. The operation time was 197.4+/-60.7 minutes (95~350) in breast approach group, and 100.1+/-19.8 minutes (65~140) in gasless transaxillary approach group. Post operative complications are; 2 cases of transient hoarseness, 8 cases of hypocalcemia (including 2 cases of permanent hypocalcemia), 2 cases of chest wall discomfort in breast approach group, and 1 case of transient hoarseness, 2 cases of transient hypocalcemia, 1 case of postoperative bleeding in gasless axillary approach group. CONCLUSION: Endoscopic thyroidectomy is a safe and technically feasible alternative to conventional thyroidectomy in patients with benign and highly selected malignant disease. We expect it can increase the extent of surgery.

Preoperative Diagnosis of Extraglandular Invasion of Thyroid Papillary Carcinoma: High Resolution Sonography versus Multidetector Computed Tomography

PURPOSE: To compare the diagnostic efficacy of high-resolution sonography (HRS) and multidetector computed tomography (MDCT) in determining the presence of extraglandular invasion of thyroid papillary cancer and to define ultrasound (US) features of perithyroidal invasion that correlate with histopathological findings. MATERIALS AND METHODS: We prospectively evaluated extracapsular invasion in 177 thyroid cancer patients using both HRS and MDCT. Receiver operating characteristics (ROC) were assessed with a four-point confidence scale (0 = no extracapsular invasion; 1 = possible invasion; 2 = probable invasion; 3 = definite invasion) by two reviewers for each imaging modality. Sensitivity, specificity, and accuracy were analyzed for each modality, along with interobserver variability. RESULTS: MDCT had a mean area under the ROC curve larger than that of HRS (HRS = 0.733, MDCT = 0.807, p < 0.05). HRS and MDCT were significantly different with regard to diagnostic sensitivity, specificity, and accuracy for extrathyroidal extension (p < 0.05; HRS = 75.7%, 66.1%, and 69.8%, respectively; MDCT = 86.7%, 69.7%, and 76%, respectively). Interobserver reliability was greater for MDCT than for HRS (kappa value, 0.861 versus 0.429). The cutoff value used in HRS for estimating the status of perithyroidal invasion was 2. CONCLUSION: HRS may be useful for preoperative investigation of thyroid papillary carcinoma extension, but it was inferior to MDCT because of lower diagnostic accuracy and lower interobserver reliability.

Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma: A 17-year Experience at a Single Institution

PURPOSE: The diffuse sclerosing variant of papillary thyroid carcinoma (DSPTC) is a rare histological subtype characterized by unique morphological features and aggressive behavior. The aim of this study was to evaluate the clinocopathologic features and outcome of DSPTC over 17 years. METHODS: Twenty-six cases of DSPTC (0.5%) were identified among 5,527 patients with papillary thyroid carcinoma treated between July 1990 and June 2007 at the Department of Surgery, Yonsei University College of Medicine. The clinicopathological features and outcome of these patients with DSPTC were evaluated. The median follow-up period was 46 months (range, 1~202 months). RESULTS: Twenty patients were females and 6 were males, the age ranged from 5 to 70 years (median 30.5 years). Histologically, most of the patients demonstrated diffuse involvement of one or both lobes of the thyroid, variable degree of lymphocytic infiltration, squamous metaplasia, psammoma bodies, extensive sclerosis and extracapsular extension, along with a high incidence of lateral neck node metastases (17/26, 65.4%). Treatment was by complete surgical resection by means of a total thyroidectomy (24/26, 92.3%), modified radical neck dissection (17/26, 65.4%) and postoperative radioactive iodine therapy (22/26, 84.6%). Recurrences were noted in 6 cases (5 locoregional recurrence and 1 distant metastasis in bone). One patient died of an unrelated disease. The 10-year overall survival and disease specific survival rates were 83.8% and 100%, retrospectively, but disease free survival was 48.0%. CONCLUSION: DSPTC showed an unfavorable clinical course with a low overall disease free survival. An aggressive therapeutic approach and close follow-up are recommended.

Hypocalcemia after Total Thyroidectomy: Incidence and Risk Factors

PURPOSE: Postoperative hypocalcemia is a common complication of thyroidectomy. This study evaluated the incidence and risk factors for postoperative hypocalcemia after total thyroidectomy. METHODS: There were 196 consecutive patients undergoing total thyroidectomy for thyroid cancer between September 2004 and February 2005 who were enrolled in this study. Patients were divided into two groups, those remaining normocalcemic (Group I) and those who had hypocalcemia requiring treatment (Group II). Group II was subdivided into a transient hypocalcemic group (Group IIA) and a permanent hypocalcemic group (Group IIB). All groups were compared with regard to age, gender, histology, coexisting disease, T stage, bilateral lesions, primary total thyroidectomy versus secondary completion thyroidectomy, extent of lymph node dissection, and autotransplantation of the parathyroid gland. RESULTS: Among all patients, 139 (71%) were in Group I, 54 (27.5%) in Group IIA and 3 (1.5%) in Group IIB. On the multivariate analysis for risk factors compared between Group I and Group II, the T4 stage was the most significant for the development of postoperative hypocalcemia. On the univariate analysis comparing factors between Group IIA and Group IIB, the T4 stage and a complete thyroidectomy were significantly related to the development of permanent hypocalcemia. CONCLUSION: The results of this study showed that the incidence of transient hypocalcemia, after total thyroidectomy, was 27.5%, while permanent hypocalcemia was detected in 1.5% of cases. The parathyroid glands should be preserved more carefully to avoid postoperative hypocalcemia in patients with high risk factors including T4 tumors and complete thyroidectomy procedures.

Central Neck Recurrence Patterns and Morbidity Following Reoperation for Recurrent Papillary Thyroid Carcinoma

PURPOSE: Central compartment reoperation for recurrent thyroid carcinoma is challenging to surgeons due to the scar tissues and adhesions and the distortion of the normal anatomic relationships. This study was carried out to investigate the central neck recurrence patterns and the surgical morbidity of reoperation for patients with papillary thyroid carcinoma. METHODS: The study population was comprised 68 papillary thyroid carcinoma patients (15 males and 53 females, median age: 50.8 years [range: 12~78 years]) who underwent reoperation for recurrent tumors in the central compartment of the neck between January 1999 and June 2007. All of the patients had undergone prior total thyroidectomy. RESULTS: Of the 68 patients, 21 recurrences occurred in the proper thyroid tissue of the thyroid bed, 43 in the central neck nodes and 4 in a combination of the central nodes and proper thyroid tissue. The common recurrent site from the proper thyroid tissue were at the berry ligaments and at the level of the upper one-third of the recurrent laryngeal nerves, while the common nodal recurrence sites were the lower-most portion of the paratracheal nodes and the right paraesophageal nodes (the lymph nodes posterior to the right recurrent laryngeal nerve). Eleven cases of transient hypocalcemia (17.5%, 11/63) and 3 cases of permanent hypocalcemia (4.3%, 3/63) were noted after reoperation. Recurrent laryngeal nerve injury occurred in 5 patients (8.1%, 5/62), but three of them were intentionally resected with the recurrent cancers. CONCLUSION: Reoperation for central neck recurrence of papillary thyroid carcinoma is associated with a higher complication rate. Meticulous surgical dissection of the central compartment based on the recurrent patterns is important to reduce injury to the recurrent laryngeal nerves and parathyroid glands.

Follicular Thyroid Carcinoma: Clinicopathologic Features, Prognostic Factors, and Treatment Strategy

PURPOSE: Follicular thyroid carcinoma (FTC) is a relatively rare form of thyroid carcinoma that often presents at a more advanced stage of disease with a higher incidence of distant metastases because of its propensity for vascular invasion. However, FTC and papillary thyroid carcinoma (PTC) have similar prognoses when they are matched for age and stage. Therefore, this study was conducted to evaluate the useful prognostic factors and determine the optimal management of FTC. METHODS: This study was conducted on 216 patients with FTC who underwent thyroidectomy at our institutions between April 1986 and August 2006. The patients included 174 women and 42 men with a mean age of 41 (4~87) years, and patients underwent follow-up evaluation for a mean period of 114 (6~253) months. The potential risk factors for treatment outcome were calculated using multivariate analysis, and the prognostic accuracy of UICC/AJCC pTNM staging, AMES, AGES, MACIS, and Degroot classification for predicting survival were compared. RESULTS: During the follow-up period, 13 (6.0%) patients developed locoregional recurrences and 8 patients (3.7%) showed distant metastases. In addition, cause specific mortality was seen in 8 patients (3.7%). The overall survival and cause-specific survival (CSS) rates at 10 years were 95.4% and 89.3%, respectively, and these cases were accurately predicted by the AMES and pTNM staging systems. The Cox proportional hazards revealed that gender (P=0.015), angioinvasion (P=0.013), invasion to adjacent structure (P=0.003), widely invasive carcinoma (P=0.028), and distant metastases at the time of presentation (P<0.001) were independent prognostic factors for survival. CONCLUSION: The extent of surgery in cases of FTC should be individualized based on the clinicopathologic findings; Conservative surgery should be adequate for cases of minimally invasive FTC without angioinvasion, however total or near-total thyroidectomy should be conducted in cases of widely invasive and minimally invasive FTC with angioinvasion.

Coexistence of Medullary and Papillary Thyroid Carcinoma / 대한내분비외과학회지

PURPOSE: The simultaneous occurrence of two distinct neoplasms derived from different cells of origin is a recognized entity. It presents uncommonly in all organs,and very rarely in the thyroid gland. METHODS: Six patients with concurrent medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC) were seen between January 2000 and June 2007. Clinicopathological features were evaluated, and follow-up for the patients was obtained. RESULTS: All patients were female, with ages ranging from 39 to 63 years (mean age, 55.4 years). Five of six patients were incidentally detected during a medical check-up. The medullary carcinomas measured from 0.5 to 4.0 cm in diameter (mean diameter, 1.72 cm), while the papillary carcinomas ranged from 0.2 to 1.4 cm in diameter (mean diameter, 0.72 cm). Treatment consisted of a total thyroidectomy (n=5) and hemithyroidectomy (n=1) with central compartment node dissection. In twopatients, prophylactic bilateral neck dissection was also added. Supplemental radioactive iodine treatment was administered in five patients. During a mean follow-up period of 41.8 months, two patients showed recurrence in the lateral neck nodes, one recurrence from a papillary carcinoma and the other recurrence from a medullary carcinoma. After re-operation for the recurrent lesions, allof the patients were alive andfree of disease. CONCLUSION: Attention should be given to the possibility of the simultaneous occurrence of MTC and PTC. Treatment for concurrent MTC and PTC should be based on the treatment for MTC, considering the more aggressive behavior of the tumor than PTC.

The Zuckerkandl's Tubercle is a Useful Anatomical Landmark for the Detection of Both the Recurrent Laryngeal Nerve and the Superior Parathyroid during Thyroid Surgery / 대한내분비외과학회지

PURPOSE: Zuckerkandl's tubercle (ZT) of the thyroid gland is a well-documented anatomical structure. This study evaluated the anatomical relationship of the ZT in terms of the recurrent laryngeal nerve (RLN) and the superior parathyroid gland (SP). METHODS: The study included 325 patients (ten patients with benign tumors and 315 patients with malignancies) who underwent thyroid surgery between February and June 2007. Tubercles were classified according to size: Grade 0 (unrecognizable), Grade I (≤ 5 mm), Grade II (6~10 mm) and Grade III (>10 mm). The incidence and size of the ZT and its positional relationship to the RLN and SP were investigated during thyroid surgery. RESULTS: ZTs were identified in most patients (right thyroid 89.3%, left thyroid 85.6%). The percentageof tubercles according to grade and location was as follows: Grade 0, right thyroid 10.7% and left thyroid 14.4%; Grade I, right thyroid 7.9% and left thyroid 11.1%; Grade II, right thyroid 43.5% and left thyroid 38.5%; Grade III, right thyroid 37.9% and left thyroid 35.9%. The most common RLN course was in a groove between the ZT and the main body of the thyroid. Most of the SPs are situated cranial to the ZTs and were located at the 1 or 2 o'clock position (96.1%) in the left thyroid and at the 10 or 11 o'clock position (95.2%) in the right thyroid. A greater distance between the ZT and the SP was seen with a decreasing size of the ZT. CONCLUSION: The ZT was identified during most thyroidectomies, and there was a constant relationship between the ZT and either the RLN or SP. Therefore, identification of the ZT and an understanding of the relationship between the ZT and either the RLN or SP are essential for the performance of safe thyroid surgery.

Papillary Thyroid Microcarcinoma: Clinicopathologic Characteristics and Treatment Strategy

PURPOSE: The clinical importance of papillary microcarcinoma (PTMC) is debatable. Because PTMC is being diagnosed with increasing frequency, it is important to describe the clinical and histological characteristics that confer aggressive behavior to this cancer. This study was carried out to evaluate the clinical and histological characteristics of PTMC and to determine an appropriate treatment strategy for such cases. METHODS: From Jan. 2000 to Dec. 2005, 1,255 patients with small papillary carcinoma, which measured less than 2.0 cm in its greater dimension, underwent total thyroidectomy at our institution. Among these patients, 633 (50.4%) had a thyorid carcinoma less than or equal to 1 cm in diameter (Group A). The clinicopathologic features and treatment outcome of these patients were evaluated and compared with the remaining 622 cases (49.6%) (Group B). RESULTS: For the patients with PTMC (Group A), there were 70 men and 563 women with a median age of 44 years (range; 12~86). During a mean follow-up of 32.5+/-18.2 months, 6 patients (0.9%) developed locoregional recurrences and 3 patients (0.5%) showed distant metastases. There was no disease-related mortality in both groups. The disease of group B was more likely to show extracapsular invasion (P 1 cm), some PTMCs show aggressive clinical behavior and locoregional recurrence. The treatment of PTMC should be individualized based on its tumor risk profiles and the clinical presentations. Moreover, performing close follow-up is essential, especially for those patients who present with cervicolateral lymph node metastases.

Follicular Variant of Papillary Thyroid Carcinoma: Clinical Features and Surgical Strategy

PURPOSE: The follicular variant of papillary thyroid carcinoma (FVPTC) is difficult to diagnose and there is continuous debate regarding the optimal extent of surgery. METHODS: One hundred sixty three patients (17 male, 146 female; mean age 43.3 years), who underwent a thyroidectomy with a final diagnosis of FVPTC were divided into the total thyroidectomy group (Group I, n=74) and the less- than total thyroidectomy group (Group II, n=89). The two groups were compared with respect to the various clinicopathological characteristics. The mean follow up duration was 64.9 months (13~247 months). RESULTS: Group I showed a significantly higher sensitivity than Group II for the diagnosis. The age of the patients in Group I was significantly older than those in Group II. The frequency of multifocality, capsular invasion, and the incidence of a cervical lymph node metastasis were significantly higher in Group I. Therefore, Group I had a higher proportion of stage III and IV. The percentage of high risk patients according to the AMES (Age, distant Metastasis, Extent of primary tumor, and tumor Size) category and MACIS (distant Metastasis, Age, Completeness of primary surgical resection, extrathyroidal Invasion, and tumor Size) score was significantly higher in Group I. However, there was a similar rate of locoregional recurrence, distant metastasis, and survival in the two groups. CONCLUSION: When a diagnosis of FVPTC is made preoperatively or intraoperatively, definitive thyroid cancer surgery can be applied using the corresponding extent of surgery for an ordinary papillary thyroid carcinoma. However, if no definitive diagnosis is made, then a less-than total thyroidectomy is recommended as the initial surgery, and a complete thyroidectomy is reserved only for high-risk patients.

Surgical Treatment of Tertiary Hyperparathyroidism after Renal Transplantation / 대한이식학회지

PURPOSE: Tertiary hyperparathyroidism (tHPT) means a persistent secondary hyperparathyroidism even after successful renal transplantation. Parathyroidectomy (PTX) is an efficient way to treat tHPT. In this study, we reviewed our single center Experience of PTX in regard to postoperative outcomes and analyzed any differences by the types of surgery. METHODS: Among 2,589 recipients who underwent renal allograft between April. 1979 and Dec. 2006, 11 patients (0.4%) were identified to have tHPT and underwent PTX. Levels of intact parathyroid hormone (iPTH) and serum calcium were measured before and after PTX to evaluate therapeutic effect, and serum-creatinine and GFR using the Modification of Diet in Renal Disease (MDRD) equation to investigate any effect to graft function. RESULTS: One patient showed persistent hyperparathyroidism and hypercalcemia after subtotal PTX. We experienced 10 successful PTXs in which 2 total PTX with autotransplantations, 4 subtotal PTXs and 4 limited PTXs. Level of iPTH and serum calcium were at normal range after PTX. Serum creatinine increased and estimated GFR decreased after PTX. Total PTX with autotransplantation showed a tendency of more decrease in the values of iPTH, and GFR after PTX than Subtotal PTX. CONCLUSION: PTX can cure tHPT-specific symptoms and sign by the recovery of hypercalcemia but may carry the risk of deterioration of kidney graft function. Subtotal PTX rather than total PTX might be recommended in the surgical treatment of tHPT to prevent any risk of kidney graft deterioration.