Association between quality of life and patient-reported complications from surgery and radioiodine in early-stage thyroid cancer survivors: A matched-pair analysis.

BACKGROUND: Remnant radioiodine ablation is discouraged in low-risk differentiated thyroid cancer because it confers no survival advantage. The impact of remnant radioiodine ablation on health-related quality of life in these patients is not well described. We hypothesized remnant radioiodine ablation is associated with lower health-related quality of life in early-stage differentiated thyroid cancer survivors. METHODS: A retrospective matched-pair analysis was conducted in stage I differentiated thyroid cancer survivors recruited from a thyroid cancer support group. Respondents self-reported via online survey. Dysphonia and dysphagia were reported via Likert scale. Health-related quality of life was evaluated using Patient-Reported Outcomes Measurement Information System (PROMIS) 29-item profile. Respondents who received remnant radioiodine ablation were matched for age, sex, race, and years since diagnosis with respondents who did not receive remnant radioiodine ablation. PROMIS t-scores were compared between remnant radioiodine ablation and nonremnant radioiodine ablation groups, and among those with or without surgical complications. RESULTS: One hundred and twenty-two pairs were matched. There was no significant difference in incidence of self-reported hypocalcemia, infection, dysphonia, or dysphagia between remnant radioiodine ablation and no remnant radioiodine ablation groups. There was no significant difference in mean PROMIS t-scores. Of respondents reporting normal preoperative voice and swallowing, there were no significant differences in postprocedural outcomes or PROMIS scores. Regardless of remnant radioiodine ablation treatment, those with surgical complications of hypocalcemia, dysphonia, or dysphagia reported worse PROMIS scores across multiple domains. Remnant radioiodine ablation-associated xerostomia was associated with worse PROMIS scores across multiple domains. CONCLUSION: This is the first study to use PROMIS measures to evaluate the association between remnant radioiodine ablation and health-related quality of life in early-stage differentiated thyroid cancer survivors treated surgically. Surgical and remnant radioiodine ablation-associated complications were associated with significantly worse PROMIS scores across multiple domains.

The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism.

Importance: Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades. Objective: To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review: A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Findings: Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise. Conclusions and Relevance: Evidence-based recommendations were created to assist clinicians in the optimal treatment of patients with pHPT.

Thyroid carcinoma, version 2.2014.

These NCCN Guidelines Insights focus on some of the major updates to the 2014 NCCN Guidelines for Thyroid Carcinoma. Kinase inhibitor therapy may be used to treat thyroid carcinoma that is symptomatic and/or progressive and not amenable to treatment with radioactive iodine. Sorafenib may be considered for select patients with metastatic differentiated thyroid carcinoma, whereas vandetanib or cabozantinib may be recommended for select patients with metastatic medullary thyroid carcinoma. Other kinase inhibitors may be considered for select patients with either type of thyroid carcinoma. A new section on "Principles of Kinase Inhibitor Therapy in Advanced Thyroid Cancer" was added to the NCCN Guidelines to assist with using these novel targeted agents.

Impact of surgical treatment on outcomes for papillary thyroid cancer.

Based on data from SEER and the NCDB, the contemporary dominant practice pattern in the United States for patients with PTC > or =1.0 cm is a total or near-total thyroidectomy. Only approximately 10% of patients with such tumors currently undergo hemithyroidectomy. Patients from older age groups, minority ethnic groups, and the lower socioeconomic strata dominate the set of patients who undergo hemithyroidectomy. Moreover, patients at low-volume and community hospitals are less likely to undergo total thyroidectomy. These differences in practice patterns likely reflect disparities in access to health care, medication, and comprehensive cancer centers. Critics of total or near-total thyroidectomy for PTC have historically commented that "an operation not worth doing, is not worth doing well." Such comments are no longer appropriate now that compelling data exist that show an improvement in survival and recurrence after more extensive thyroid resection. If all patients with PTC > or =1.0 cm were to instead undergo total thyroidectomy, the estimated improvement in long-term survival would be approximately 2%. The differences in outcomes seem relatively small when expressed as a percentage; however, the number of patients affected would be relatively large. The incidence of these small (<2 cm, PTCs has been increasing, and now greater than 50% of the PTC in the NCDB fall into the less than 2-cm size category. There are several valid reasons why surgeons may not perform a total thyroidectomy. Hemithyroidectomy is the appropriate operation for patients with unilateral cancers who will not or cannot comply with lifelong thyroid hormone replacement. Surgical decision making may also be influenced by concerns about the risk of devastating complications such as bilateral recurrent laryngeal nerve injury or permanent hypocalcemia, neither of which are a concern with a lobectomy. Population-based volume-outcome studies have suggested that the risk of nerve injury and hypocalcemia is significantly greater at low-volume centers. Importantly, the majority of patients in the United States undergo thyroid surgery at low-volume centers. Unless the surgeon's complication rate for thyroidectomy is substantially lower than the 2% improvement in survival rate offered by the more extensive operation, total thyroidectomy should not be offered. Alternatively, patients could be referred, if possible, to high-volume surgeons to minimize the risk of complications while offering the operation that affords the best long-term outcomes. Total or near-total thyroidectomy for PTCs greater than 1 cm in size yields the best outcome in terms of risk of recurrence and death. The surgical treatment of PTC needs to be individualized, however. based on the patient, the tumor, and the experience of the surgeon to offer the best outcome.