Résumé
These guidelines aim to establish the standard practice for diagnosing and treating patients with differentiated thyroid cancer (DTC). Based on the Korean Thyroid Association (KTA) Guidelines on DTC management, the “Treatment of Advanced DTC” section was revised in 2024 and has been provided through this chapter. Especially, this chapter covers surgical and nonsurgical treatments for the local (previous surgery site) or regional (cervical lymph node metastasis) recurrences. After drafting the guidelines, it was finalized by collecting opinions from KTA members and related societies. Surgical resection is the preferred treatment for local or regional recurrence of advanced DTC. If surgical resection is not possible, nonsurgical resection treatment under ultrasonography guidance may be considered as an alternative treatment for local or regional recurrence of DTC. Furthermore, if residual lesions are suspected even after surgical resection or respiratory-digestive organ invasion, additional radioactive iodine and external radiation treatments are considered.
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Thyroid surgery complications include voice change, vocal fold paralysis, and hypoparathyroidism. The voice status should be evaluated pre- and post-surgery. In patients with voice change, laryngeal visualization is needed.Intraoperative neuromonitoring helps reduce recurrent laryngeal nerve injury. The measurement of serum calcium, parathyroid hormone, and 25-hydroxyvitamin D levels is recommended to evaluate perioperative parathyroid function and prescribe supplementation preoperatively if necessary. For postoperative hypoparathyroidism, vitamin D and oral calcium supplementation are indicated based on serum parathyroid hormone and calcium levels and the severity of symptoms or signs of hypocalcemia. If long-term treatment is required, the appropriateness of treatment should be evaluated based on the disease itself and the consideration of potential benefits and harms from long-term replacement.
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Pediatric differentiated thyroid cancers (DTCs), mostly papillary thyroid cancer (PTC, 80-90%), are diagnosed at more advanced stages with larger tumor sizes and higher rates of locoregional and/or lung metastasis. Despite the higher recurrence rates of pediatric cancers than of adult thyroid cancers, pediatric patients demonstrate a lower mortality rate and more favorable prognosis. Considering the more advanced stage at diagnosis in pediatric patients, preoperative evaluation is crucial to determine the extent of surgery required. Furthermore, if hereditary tumor syndrome is suspected, genetic testing is required. Recommendations for pediatric DTCs focus on the surgical principles, radioiodine therapy according to the postoperative risk level, treatment and follow-up of recurrent or persistent diseases, and treatment of patients with radioiodine-refractory PTCs on the basis of genetic drivers that are unique to pediatric patients.
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Differentiated thyroid cancer demonstrates a wide range of clinical presentations, from very indolent cases to those with an aggressive prognosis. Therefore, diagnosing and treating each cancer appropriately based on its risk status is important. The Korean Thyroid Association (KTA) has provided and amended the clinical guidelines for thyroid cancer management since 2007. The main changes in this revised 2024 guideline include 1) individualization of surgical extent according to pathological tests and clinical findings, 2) application of active surveillance in low-risk papillary thyroid microcarcinoma, 3) indications for minimally invasive surgery, 4) adoption of World Health Organization pathological diagnostic criteria and definition of terminology in Korean, 5) update on literature evidence of recurrence risk for initial risk stratification, 6) addition of the role of molecular testing, 7) addition of definition of initial risk stratification and targeting thyroid stimulating hormone (TSH) concentrations according to ongoing risk stratification (ORS), 8) addition of treatment of perioperative hypoparathyroidism, 9) update on systemic chemotherapy, and 10) addition of treatment for pediatric patients with thyroid cancer.
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The primary objective of initial treatment for thyroid cancer is minimizing treatment-related side effects and unnecessary interventions while improving patients’ overall and disease-specific survival rates, reducing the risk of disease persistence or recurrence, and conducting accurate staging and recurrence risk analysis. Appropriate surgical treatment is the most important requirement for this purpose, and additional treatments including radioactive iodine therapy and thyroid-stimulating hormone suppression therapy are performed depending on the patients’ staging and recurrence risk. Diagnostic surgery may be considered when repeated pathologic tests yield nondiagnostic results (Bethesda category 1) or atypia of unknown significance (Bethesda category 3), depending on clinical risk factors, nodule size, ultrasound findings, and patient preference. If a follicular neoplasm (Bethesda category 4) is diagnosed pathologically, surgery is the preferred option. For suspicious papillary carcinoma (suspicious for malignancy, Bethesda category 5), surgery is considered similar to a diagnosis of malignancy (Bethesda category 6). As for the extent of surgery, if the cancer is ≤1 cm in size and clinically free of extrathyroidal extension (ETE) (cT1a), without evidence of cervical lymph node (LN) metastasis (cN0), and without obvious reason to resect the contralateral lobe, a lobectomy can be performed. If the cancer is 1-2 cm in size, clinically free of ETE (cT1b), and without evidence of cervical LN metastasis (cN0), lobectomy is the preferred option. For patients with clinically evident ETE to major organs (cT4) or with cervical LN metastasis (cN1) or distant metastasis (M1), regardless of the cancer size, total thyroidectomy and complete cancer removal should be performed at the time of initial surgery. Active surveillance may be considered for adult patients diagnosed with low-risk thyroid papillary microcarcinoma. Endoscopic and robotic thyroidectomy may be performed for low-risk differentiated thyroid cancer when indicated, based on patient preference.
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Conventional surgery through a transcervical incision is indicated for the treatment of certain tumors in the head and neck. However, this method can cause multiple problems, including scarring and cosmetic concerns. The endoscope-assisted hairline approach, which serves as an alternative to conventional surgical procedures, is gaining popularity due to its excellent cosmetic and functional outcomes. However, given the anatomical complexity involved, the endoscope-assisted hairline technique is not frequently employed in head and neck surgery. The evolution of the hairline surgical approach has been influenced by changes in disease conditions and recent advances in surgical tools. This review article discusses the use of endoscope-assisted hairline approaches in the resection of head and neck masses, focusing on the surgical procedure and postoperative clinical outcomes.
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Traditional open surgery is indicated for the treatment of selected tumor subsites in the head and neck. However, it can cause major cosmetic problems and functional pathologies. The endoscopically-assisted transoral approach is increasingly preferred in some surgical fields due to its superior cosmetic and functional outcomes. Nonetheless, endoscopically-assisted transoral approach is not yet standard in the head and neck due to their anatomical complexity. The transoral surgical approach has been used for head and neck masses since the 1960s, and its application continues to evolve with changing disease conditions and recent innovations in surgical instruments. The potential for wide application of transoral surgery continues to be investigated, with a focus on minimizing occurrence of the complications. This review presents details of the surgical procedure and postoperative clinical outcomes, as well as endoscopically-assisted scar-free techniques for the resection of midline neck masses.
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Objectives@#. Head and neck squamous cell carcinomas (HNSCs) are frequently diagnosed at the locoregional advanced stage (stage IVa), but controversy remains regarding whether stage IVa HSNCs should be treated with upfront surgery or definitive chemoradiation therapy (CRT). The purpose of this study was to compare overall survival (OS) and disease-free survival (DFS) in patients with stage IVa HNSC treated primarily by surgery with curative intent with/without (neo)adjuvant treatment (surgery group) versus those treated primarily with CRT (CRT group). @*Methods@#. We reviewed data of 1,033 patients with stage IVa HNSC treated with curative intent at 17 cancer centers between 2010 and 2016. @*Results@#. Among 1,033 patients, 765 (74.1%) received upfront surgery and 268 (25.9%) received CRT. The 5-year OS and DFS rates were 64.4% and 62.0% in the surgery group and 49.5% and 45.4% in the CRT group, respectively. In multivariate analyses, OS and DFS were better in the surgery group than in the CRT group (odds ratio [OR] for death, 0.762; 95% confidence interval [CI], 0.592–0.981; OR for recurrence, 0.628; 95% CI, 0.492–0.802). In subgroup analyses, the OS and DFS of patients with oropharyngeal cancer were better in the surgery group (OR for death, 0.548; 95% CI, 0.341–0.879; OR for recurrence, 0.598; 95% CI, 0.377–0.948). In the surgery group, patients with laryngeal cancer showed better OS (OR for death, 0.432; 95% CI, 0.211–0.882), while those with hypopharyngeal cancer DFS was improved (OR for recurrence, 0.506; 95% CI, 0.328–0.780). @*Conclusion@#. A survival benefit from surgery may be achieved even in patients with stage IVa HNSC, particularly those with oropharyngeal and laryngeal cancer. Surgery led to a reduction in the recurrence rate in patients with hypopharyngeal cancer.
Résumé
Traditional open surgery is indicated for the treatment of selected tumor subsites in the head and neck. However, it can cause major cosmetic problems and functional pathologies. The endoscopically-assisted transoral approach is increasingly preferred in some surgical fields due to its superior cosmetic and functional outcomes. Nonetheless, endoscopically-assisted transoral approach is not yet standard in the head and neck due to their anatomical complexity. The transoral surgical approach has been used for head and neck masses since the 1960s, and its application continues to evolve with changing disease conditions and recent innovations in surgical instruments. The potential for wide application of transoral surgery continues to be investigated, with a focus on minimizing occurrence of the complications. This review presents details of the surgical procedure and postoperative clinical outcomes, as well as endoscopically-assisted scar-free techniques for the resection of midline neck masses.
Résumé
Objectives@#. Head and neck squamous cell carcinomas (HNSCs) are frequently diagnosed at the locoregional advanced stage (stage IVa), but controversy remains regarding whether stage IVa HSNCs should be treated with upfront surgery or definitive chemoradiation therapy (CRT). The purpose of this study was to compare overall survival (OS) and disease-free survival (DFS) in patients with stage IVa HNSC treated primarily by surgery with curative intent with/without (neo)adjuvant treatment (surgery group) versus those treated primarily with CRT (CRT group). @*Methods@#. We reviewed data of 1,033 patients with stage IVa HNSC treated with curative intent at 17 cancer centers between 2010 and 2016. @*Results@#. Among 1,033 patients, 765 (74.1%) received upfront surgery and 268 (25.9%) received CRT. The 5-year OS and DFS rates were 64.4% and 62.0% in the surgery group and 49.5% and 45.4% in the CRT group, respectively. In multivariate analyses, OS and DFS were better in the surgery group than in the CRT group (odds ratio [OR] for death, 0.762; 95% confidence interval [CI], 0.592–0.981; OR for recurrence, 0.628; 95% CI, 0.492–0.802). In subgroup analyses, the OS and DFS of patients with oropharyngeal cancer were better in the surgery group (OR for death, 0.548; 95% CI, 0.341–0.879; OR for recurrence, 0.598; 95% CI, 0.377–0.948). In the surgery group, patients with laryngeal cancer showed better OS (OR for death, 0.432; 95% CI, 0.211–0.882), while those with hypopharyngeal cancer DFS was improved (OR for recurrence, 0.506; 95% CI, 0.328–0.780). @*Conclusion@#. A survival benefit from surgery may be achieved even in patients with stage IVa HNSC, particularly those with oropharyngeal and laryngeal cancer. Surgery led to a reduction in the recurrence rate in patients with hypopharyngeal cancer.
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As population ages, much more elderly patients have been diagnosed with head and neck cancer especially in Korea. Diverse factors such as comorbidities and disabilities make the establishment of evidence-based guidance more challenging. Chronological age, literally measured in days, months and years from the time the individual was born, is not an ideal predictor in determining personal health condition; individualization of treatment protocols with identifying the concept of frailty is the key to produce an advanced treatment plan of elderly patients suffering from head and neck malignancy. Frailty is a type of geriatric syndrome which refers to the status with age-associated declines in physiologic function and increased vulnerability to stress conditions independent of age. Therefore, screening the status of frailty may be beneficial for the elderly patients to determine decent treatment option and maximize the efficiency. In order to provide otolaryngologists prognostic information adapting the concept of frailty, research papers published from 2000 to 2018 are comprehensively reviewed in this article. For optimal care of elderly patients with head and neck cancer, frailty is definitely required to be assessed in order to establish an ideal treatment option and increase the efficacy of the treatment.
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As population ages, much more elderly patients have been diagnosed with head and neck cancer especially in Korea. Diverse factors such as comorbidities and disabilities make the establishment of evidence-based guidance more challenging. Chronological age, literally measured in days, months and years from the time the individual was born, is not an ideal predictor in determining personal health condition; individualization of treatment protocols with identifying the concept of frailty is the key to produce an advanced treatment plan of elderly patients suffering from head and neck malignancy. Frailty is a type of geriatric syndrome which refers to the status with age-associated declines in physiologic function and increased vulnerability to stress conditions independent of age. Therefore, screening the status of frailty may be beneficial for the elderly patients to determine decent treatment option and maximize the efficiency. In order to provide otolaryngologists prognostic information adapting the concept of frailty, research papers published from 2000 to 2018 are comprehensively reviewed in this article. For optimal care of elderly patients with head and neck cancer, frailty is definitely required to be assessed in order to establish an ideal treatment option and increase the efficacy of the treatment.
Sujets)
Sujet âgé , Humains , Protocoles cliniques , Comorbidité , Diagnostic , Tumeurs de la tête et du cou , Tête , Corée , Dépistage de masse , CouRésumé
A calcified structure blocking the flow of saliva into the mouth is a major cause of salivary dysfunction. If a stone is detected, the goal of treatment would be to remove it. Furthermore, the fundamental treatment for preventing recurrence, although depending on the location and size of the stone, is salivary gland resection. The submandibular gland duct and hilum stone is usually removed by transoral approach. If there are multiple stones in the submandibular gland and the duct, it would be necessary to carry out resection of submandibular gland, using the intra-oral approach. We recently experienced a case of multiple stone in the submandibular gland and the duct in a 73-year-old man, who presented with the right submandibular area swelling after meals. We removed the submandibular gland and duct stone without intra-oral approach and present this case with a review of the literature.
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Aspiration, the entry of material into the airway below the true vocal folds, has been reported in various type of postsurgical head and neck patients. The important of correctly identifying the cause of aspiration in the head and neck surgical patient. Clearly each cause represents a different physiologic or anatomic disorder which requires different management strategy. We discuss about the cause of aspiration during head and neck treatment.
Sujets)
Humains , Tête , Cou , Plis vocauxRésumé
Leiomyosarcoma is a malignant tumor originating from the smooth muscle tissue, found mostly in the genitourinary tract, gastrointestinal tract and peritoneum. However, leiomyosarcoma of the parotid gland is extremely rare as there is only smooth muscle in the blood vessels of the parotid gland. There has been a only single case of metastatic leiomyosarcoma reported in the English journal. Herein we report an extremely rare case of leiomyosarcoma of the parotid gland of a 66-year-old man who initially suffered from primary renal leiomyosarcoma.
Sujets)
Sujet âgé , Humains , Vaisseaux sanguins , Tube digestif , Léiomyosarcome , Muscles lisses , Métastase tumorale , Glande parotide , PéritoineRésumé
Fibromatosis is generally a benign tumor that arises from the musculoaponeurotic tissues of the body, rarely occurring in the head and neck region. This can be treated with a good prognosis, but sometimes recurs as a local invasion. Preoperative core needle biopsy and MR images are necessary to diagnose preoperatively and outline the tumor extent. The mainstay of treatment is complete surgical excision. Nonetheless, an excision is often difficult because of the complex anatomy or proximity of the tumor to vital structures in the head and neck region. We report a rare case of desmoid-type fibromatosis that occurred in the neck, closely attached to the transverse process of the cervical vertebra. The present article covers an extensive analysis of the case with a review of the related literature.
Sujets)
Femelle , Biopsie au trocart , Vertèbres cervicales , Fibrome , Fibromatose agressive , Tête , Cou , Pronostic , RachisRésumé
Dermatofibrosarcoma protuberans is a rare type of cancer, a soft tissue sarcoma that develops in the deep layers of skin. It is a locally aggressive tumor with a high recurrence rate but the metastasis rarely occurs. The first sign of dermatofibrosarcoma protuberans is often a small bump on the skin. It may resemble a deep-seated pimple of rough patch of skin. The tumor typically grows slowly and can become a raised nodule. Therefore, it is likely to be misdiagnosed as keloid, basal cell carcinoma and scleroderma. We recently experienced a case of dermatofibrosarcoma protuberans in a 63-year-old man, who presented with anterior lower neck mass. We present this case with a review of the literature.
Sujets)
Humains , Adulte d'âge moyen , Carcinome basocellulaire , Dermatofibrosarcome , Chéloïde , Cou , Métastase tumorale , Récidive , Sarcomes , PeauRésumé
Dermatofibrosarcoma protuberans is a rare type of cancer, a soft tissue sarcoma that develops in the deep layers of skin. It is a locally aggressive tumor with a high recurrence rate but the metastasis rarely occurs. The first sign of dermatofibrosarcoma protuberans is often a small bump on the skin. It may resemble a deep-seated pimple of rough patch of skin. The tumor typically grows slowly and can become a raised nodule. Therefore, it is likely to be misdiagnosed as keloid, basal cell carcinoma and scleroderma. We recently experienced a case of dermatofibrosarcoma protuberans in a 63-year-old man, who presented with anterior lower neck mass. We present this case with a review of the literature.
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BACKGROUND AND OBJECTIVES: Laryngopharyngeal reflux disease (LPRD) is relatively common disease. N-acetyl cysteine (NAC) has both mucolytic and antioxidant effect, also may be beneficial in inflammatory airway diseases. The purpose of this study was to evaluate the efficacy and safety of inhaled NAC therapy in LPRD. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 525 LPRD patients at 12 medical centers. Finally 401 patients subjected to inhaled NAC therapy for 2 months were enrolled in the study. We analyzed the change of Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) after use of NAC for 4 weeks and 8 weeks in addition to the patient's compliance of the treatment. RESULTS: The RSI score significantly decreased from 19.87±6.34 to 12.78±6.93 after 4 weeks and to 10.65±7.47 after 8 weeks. The RFS score also significantly decreased from 9.29±3.4 to 7.17±3.41 after 4 weeks and to 6.1±3.73 after 8 weeks (p<0.05). During the treatment periods, 42 patients (10.4%) reported to have 80 episodes of discomfort. Throat discomfort (33%) and nausea (28%) were most common complaints, but the duration of discomfort was usually less than 4 weeks. CONCLUSION: Inhaled NAC treatment is highly effective for the reduction of both subjective and objective findings in LPRD patients. This study will provide the evidence of new treatment option for patients with LPRD. However, further studies will be needs to assess the real effect of inhaled NAC therapy as a standard treatment regimen of LPRD.
Sujets)
Humains , Antioxydants , Compliance , Cystéine , Cystine , Inspiration , Reflux laryngopharyngé , Dossiers médicaux , Nausée , Pharynx , Études rétrospectivesRésumé
Hyalinizing trabecular adenoma of the thyroid gland is a rare benign neoplasm. It is characterized by an encapsulated nodule, trabecular arrangement of polygonal, oval, elongated cells, and hyalinized stroma. It is easily confused with medullary thyroid carcinoma or papillary thyroid carcinoma. Distinguishment with pathologic finding and immunohistochemical studies are needed to make a definite diagnosis. We recently experienced a case of hyalinizing trabecular adenoma of the thyroid gland. A 73-year-old woman present with an incidentally detected left thyroid mass. Fine needle aspiration was performed and papillary thyroid carcinoma was suspected. However, the surgical specimen revealed a hyalinizing trabecular adenoma. We present this case with a review of the literature.