Radioactive iodine administration is not associated with improved disease-specific survival in classic papillary thyroid carcinoma greater than 4 cm confined to the thyroid.

BACKGROUND: We aimed to evaluate the impact of radioactive iodine on disease-specific survival in intrathyroidal (N0M0) papillary thyroid carcinoma >4 cm, given conflicting data in the American Thyroid Association guidelines regarding their management. METHODS: The Surveillance, Epidemiology, and End Results database was queried for N0M0 classic papillary thyroid carcinoma >4 cm. Kaplan-Meier estimates were performed to compare disease-specific survival between radioactive iodine-treated and untreated groups. A multivariable Cox regression was performed to identify predictors of disease-specific survival. RESULTS: There were more patients aged ≥55 (41.7% vs 32.3%, P = .001) and fewer multifocal tumors (25.3% vs 30.6%, P = .006) in the no radioactive iodine group. Ten-year disease-specific survival was similar between the radioactive iodine treated and untreated groups (97.2% vs 95.6%, P = .34). Radioactive iodine was not associated with a significant disease-specific survival benefit (adjusted hazard ratio = 0.78, confidence interval [0.39-1.58], P = .49). Age ≥55 (adjusted hazard ratio = 3.50, confidence interval [1.69-7.26], P = .001) and larger tumor size (adjusted hazard ratio = 1.04, confidence interval [1.02-1.06], P < .001) were associated with an increased risk of disease-specific death. Subgroup analyses did not demonstrate improved disease-specific survival with radioactive iodine in patients ≥55 and in tumors >5 cm. CONCLUSION: Adjuvant radioactive iodine administration in classic papillary thyroid carcinoma >4 cm confined to the thyroid did not significantly impact disease-specific survival. Thus, these patients may not require routine treatment with adjuvant radioactive iodine.

Application of Non-Ligation Technique in Thyroidectomy.

Objective: This study aimed to analyze the difference between non-ligation and traditional ligation techniques for papillary thyroid micro-carcinoma (PTMC) patients. Methods: Patients undergoing thyroidectomy in the Department of General Surgery, Ruijin Hospital, affiliated with Shanghai Jiao Tong University, Lu Wan Branch, were retrospectively enrolled. The gender, age, operation method, operation duration, tumor size, size of thyroidectomy specimen, postoperative bleeding, drainage volume on the first postoperative day, preoperative and postoperative levels of parathyroid hormone (PTH), and blood calcium were collected. Results: Compared with the traditional ligation technique, the non-ligation technique significantly shortened the operation time (69.36 ± 1.38 vs. 82.72 ± 2.12, P < .0001) and reached less variation of the serum calcium (2.32 ± 0.01 vs 2.28 ± 0.01, P < .001) and PTH (26.58 ± 0.08 vs 22.01 ± 1.04, P < .05) on the first postoperative day, and the above biochemical indicators returned to normal 3 weeks after surgery. The PTH in the No-ligation technique group was 7.20± 1.99, which was significantly lower than that in the Traditional ligation group (20.78± 3.78) (P < .01). Conclusion: No-ligation technique can significantly reduce the operation time in thyroidectomy but may temporarily affect the levels of parathyroid hormone and blood calcium, and the above changes returned to normal 3 weeks after surgery. These results highlighted that No-ligation technique can benefit patients and will be a favorable treatment method.

Postoperative recurrence of diffuse sclerosing thyroid cancer in an adolescent patient: A case report.

BACKGROUND: Papillary thyroid cancer is an inert malignant tumor with a good response to surgical treatment, low recurrence and metastasis rate, and good prognosis. Diffuse sclerosing thyroid cancer is an invasive subtype that is more common in young people, with a higher rate of lymph node metastasis and recurrence, and a relatively poor prognosis. PATIENT CONCERNS: A 13-year-old girl underwent radical surgery for diffuse sclerosing thyroid cancer. Eight years later, due to a large number of lymph node metastases, she underwent another radical surgery on her neck lymph nodes. METHODS: The patient thyroid ultrasound and neck enhanced CT indicated that the patient had multiple enlarged lymph nodes in the neck with irregular morphology and structure, and the possibility of metastatic lymph nodes was high. Subsequently, the patient underwent thyroid fine-needle aspiration and the results showed that cancer cells were detected in both cervical lymph nodes. DIAGNOSIS: The patient was diagnosed with bilateral cervical lymph node metastases after thyroid surgery. RESULTS: After the second surgery, the patient recovered well, and no residual or focal iodine uptake tissue was found on the enhanced CT examination. CONCLUSION: As diffuse sclerosing thyroid cancer is prone to lymph node and recurrent metastases, once it is diagnosed, radical treatment should be actively performed. Postoperative adjuvant radiation therapy should be administered according to the patient condition and regular follow-ups should be conducted to monitor neck lymph node metastasis.

Results of thyroidectomies according to general surgeons and otolaryngologist and cervico faciale surgeons at the general Hospital of Reference of Niamey, what differences in the protocols of management?

OBJECTIVE: To evaluate the surgical management of thyroid pathologies at the Reference General Hospital. METHODS: This was a retro-prospective study over 4 years 6 months carried out in the departments of General and Digestive Surgery (GDS) and Otorhinolaryngology and Cervico Facial Surgery (ORL/FCS). It involved 182 patients who underwent thyroid surgery. RESULTS: A frequency of thyroidectomy of 9.46% was found. Females predominated with a sex ratio of 0.1. The average age of patients was 42.85 years, a standard deviation 12.80. 84.06% of patients had consulted for anterior cervical mass. EU-TIRADS score 3 represented 7,14% of cases. Heteromultinodular goiter was the main indication for thyroid surgery (59.34%). Total thyroidectomy was the most commonly performed gesture in general surgery in 88,23% (n = 105), in Otorhinolaryngology, it was in the same proportion as lobo-isthmectomy at 47.61% (n = 30). The first route was video-assisted thyroidectomy 2.2% (n = 4). The recurrent laryngeal nerve was dissected and seen in 159 cases (87.36%) and parathyroid glands were also seen and preserved in 58.24% of cases (n = 106). In immediate postoperative surgery, the main complications were unilateral recurrent paralysis with dysphonia in 3.3% (n = 6) and compressive hematoma in 2.2% (n = 4). No deaths had been recorded. CONCLUSION: Total thyroidectomy was the most performed procedure in department of General and Digestive Surgery. Routine oral calcium and vitamin D supplementation in the general surgery ward, reduces the occurrence of hypocalcemia after total thyroidectomy and allows a safe and early exit. Standardizing protocols will further reduce complications.

The utility of parathyroid autofluorescence as an adjunct in thyroid and parathyroid surgery 2023.

Thyroid and parathyroid surgery requires careful dissection around the vascular pedicle of the parathyroid glands to avoid excessive manipulation of the tissues. If the blood supply to the parathyroid glands is disrupted, or the glands are inadvertently removed, temporary and/or permanent hypocalcemia can occur, requiring post-operative exogenous calcium and vitamin D analogues to maintain stable levels. This can have a significant impact on the quality of life of patients, particularly if it results in permanent hypocalcemia. For over a decade, parathyroid tissue has been noted to have unique intrinsic properties known as "fluorophores," which fluoresce when excited by an external light source. As a result, parathyroid autofluorescence has emerged as an intra-operative technique to help with identification of parathyroid glands and to supplement direct visualization during thyroidectomy and parathyroidectomy. Due to the growing body of literature surrounding Near Infrared Autofluorescence (NIRAF), we sought to review the value of using autofluorescence technology for parathyroid detection during thyroid and parathyroid surgery. A literature review of parathyroid autofluorescence was performed using PubMED. Based on the reviewed literature and expert surgeons' opinions who have used this technology, recommendations were made. We discuss the current available technologies (image vs. probe approach) as well as their limitations. We also capture the opinions and recommendations of international high-volume endocrine surgeons and whether this technology is of value as an intraoperative adjunct. The utility and value of this technology seems promising and needs to be further defined in different scenarios involving surgeon experience and different patient populations and conditions.

The importance of sentinel lymph node diagnostic biopsy from the lateral neck compartment in the surgical treatment of papillary thyroid cance.

OBJECTIVES: The aim of our study is to determine whether mapping the lymphatic drainage and diagnostic excision of lymph nodes from lateral neck compartment is able to detect ultrasound unknown metastases in this compartment early and thus favorably affect the prognosis of patients with papillary thyroid cancer (PTC). BACKGROUND: Lymph node involvement in the lateral neck compartment is seen in 30-60 % of patients with PTC at the time of diagnosis and affects the prognosis of patients in terms of disease recurrence. METHODS: From June 2012 to December 2016, 154 patients with no evidence of lateral nodal involvement on imaging studies were treated with total thyroidectomy and central comparment neck dissection. A volume of 0.2 ml of Patent Blue dye was applied in the upper half of the thyroid gland with subsequent exposure of lymphatic drainage in the lateral compartment and 2-3 sentinel lymph nodes (SLN) were removed for frozen section (Group 1). In case of metastatic involvement, a lateral comparment neck dissection was performed. The reference groups were composed of a set of patients without detected lymphatic drainage (Group 2) and a set of patients who underwent lateral compartment neck dissection for preoperatively detected metastases in the lymph nodes (Group 3). The biochemical, structural and overall persistence of the disease at the time of administration of adjuvant radioiodine ablation was evaluated. RESULTS: The SLN identification rate was 95.45 %. In Group 1, a total of 32 patients had a positive SLN. Out of these, 24 patients had positive SLNs based on the analysis of frozen section, while in 8 patients, the positive diagnosis was confirmed through definitive histology. The comparison of data from the entire follow-up period in all three groups of patients revealed statistically significant differences in persistence of disease, namely in favor of Group 1. The percentage of reoperations for persistence and recurrence of disease was significantly lowest in Group 1 (2.04 %) compared to Groups 2 and 3 (6.94 % and 45.45 % respectively). CONCLUSION: The method is safe and sensitive for detecting unknown lymph node metastases in the lateral neck compartment, and may facilitate a decision to perform accurate surgical treatment of patients with PTC (Tab. 4, Fig. 2, Ref. 38).

Preoperative and postoperative optimisation of patients undergoing thyroid surgery: a multicentre quality improvement project at Barts Health NHS Trust.

Hypocalcaemia following thyroid surgery can occur in up to 38% of patients. With over 7100 thyroid surgeries performed in 2018 in the UK, this is a common postoperative complication. Undertreated hypocalcaemia can result in cardiac arrhythmias and death. Preventing adverse events from hypocalcaemia requires preoperative identification and treatment of at-risk patients with vitamin D deficiency, timely recognition of postoperative hypocalcaemia and prompt appropriate treatment with calcium supplementation. This project aimed to design and implement a perioperative protocol for prevention, detection and management of post-thyroidectomy hypocalcaemia. A retrospective audit of thyroid surgeries (n=67; October 2017 to June 2018) was undertaken to establish baseline practice of (1) preoperative vitamin D levels assessment, (2) postoperative calcium checks and incidence of postoperative hypocalcaemia and (3) management of postoperative hypocalcaemia. A multidisciplinary team approach following quality improvement principles was then used to design a perioperative management protocol with all relevant stakeholders involved. After dissemination and implementation, the above measures were reassessed prospectively (n=23; April-July 2019). The percentage of patients having their preoperative vitamin D measured increased from 40.3% to 65.2%. Postoperative day-of-surgery calcium checks increased from 76.1% to 87.0%. Hypocalcaemia was detected in 26.8% of patients before and 30.43% of patients after protocol implementation. The postoperative component of the protocol was followed in 78.3% of patients. Limitations include low number of patients which precluded from analysis of the impact of the protocol on length of stay. Our protocol provides a foundation for preoperative risk stratification and prevention, early detection and subsequent management of hypocalcaemia in thyroidectomy patients. This aligns with enhanced recovery protocols. Moreover, we offer suggestions for others to build on this quality improvement project with the aim to further advance the perioperative care of thyroidectomy patients.

Impact of Modified Thoracic Breast Approach Lumpectomy on Prognosis of Recurrence in Radical Thyroid Carcinoma Patients.

Objective: This study aimed to compare the efficacy and safety of endoscopic radical thyroidectomy (ERT) via modified breast approach (MBA) with conventional open thyroidectomy in treating thyroid carcinoma (TC). Methods: One hundred patients with TC were randomized into a research group (treated with modified thoracic breast approach lumpectomy) and a control group (treated with traditional open surgery). Clinical efficacy, adverse effects, operative time, intraoperative bleeding, postoperative drainage, and length of stay (LOS) were compared between the groups. Serum calcium and parathyroid hormone levels were measured preoperatively and on postoperative days 1 and 5. Patients were followed up for 1-year prognosis, including prognostic survival, TC recurrence rate, and factors affecting their prognosis. Results: There was no difference in total treatment efficiency between the groups, but the incidence of adverse effects, intraoperative bleeding, postoperative drainage, and LOS were lower in the research group, while the operative time was higher in the control group. Serum calcium and parathyroid hormone were insufficient in both groups on postoperative day 1 compared to preoperative levels, with higher levels in the research group. On postoperative day 5, there was no difference between the groups. TC recurrence was lower in the research group, and logistic regression analysis showed that age and surgical method were independent factors affecting prognostic recurrence in TC patients. Conclusion: Modified thoracic breast approach lumpectomy for radical TC is a safe and effective technique that can improve patients' prognosis of recurrence. It is recommended for clinical practice.

Perioperative outcomes in children with Hashimoto's thyroiditis undergoing total thyroidectomy.

BACKGROUND: Hashimoto's thyroiditis (HT) affects 1-2 % of the pediatric population. In adults with HT, thyroidectomy is considered challenging and prone to postoperative complications due to the chronic inflammatory process. However, the complications of thyroidectomy among children with HT have not been established. The objective of our study was to evaluate whether children with HT undergoing total thyroidectomy for presumed thyroid cancer have higher complication rates than children without HT. METHODS: A retrospective cohort study of children who underwent total thyroidectomy by high-volume pediatric otolaryngologists between 2014 and 2021. RESULTS: 111 patients met inclusion criteria, 15 of these were diagnosed with HT preoperatively. Operative time and length of admission were similar among the groups. Postoperatively, patients with HT were more likely to have low levels of parathyroid hormone (60 % vs 26 %, p = 0.014) and transient hypocalcemia compared to non-HT patients, present with symptomatic hypocalcemia (67 % vs 27 %, p = 0.006), demonstrate EKG changes (20 % vs 6.3 %, p = 0.035) within 24 h of surgery, and to require both oral and intravenous calcium supplements (80 % vs 35 %, p = 0.001 and 60 % vs 22 % p = 0.004 respectively). Persistent hypocalcemia at 6 months follow-up, and recurrent laryngeal nerve paralysis rates were similar between groups. Parathyroid tissue was found in the thyroid specimen of 9 (60 %) HT patients vs 34 (35 %) non-HT patients (p = 0.069). CONCLUSIONS: The risk of permanent complications among children with HT following thyroidectomy is low. However, patients with HT are more likely to develop symptomatic transient hypocalcemia and to require oral and intravenous calcium supplements in the immediate post-operative period compared to non-HT patients. Tailoring a perioperative treatment protocol to optimize calcium levels may be considered for children with HT.

The role of preoperative vitamin D and calcium in preventing post-thyroidectomy hypocalcaemia: a systematic review.

BACKGROUND: The thyroid gland plays an important endocrine function regulating metabolism, growth and development. A variety of benign and malignant conditions necessitate surgical removal of the thyroid gland, either in its entirety, or partially. Thyroidectomy is the most commonly undertaken endocrine surgery. Hypocalcaemia, occurring at a rate of approximately 25%, is the most common complication following total thyroidectomy. Hypocalcaemia can increase healthcare costs requiring further investigations, treatment and delaying discharge. Severe hypocalcaemia can be potentially life threatening. It has been demonstrated that routine post-operative supplementation with Vitamin D and calcium, can reduce post-operative hypocalcaemia, at present it is unclear whether preoperative supplementation has a similar effect. METHODS: This systematic review includes randomised controlled trials on human adult subjects, who received preoperative Vitamin D and/or calcium, and which studied the effect on post-operative hypocalcaemia following total or near total thyroidectomy. There were no restrictions in respect of post-operative supplementation regimen. Studies were limited to those published in English. RESULT: Seven of the eleven trials demonstrated a reduction in either laboratory or clinical hypocalcaemia with preoperative supplementation. This benefit was most likely to be seen when postoperative supplementation was performed on an as needed basis. IV calcium was required to treat resistant or severe hypocalcaemia, in five of the eleven trials, in each of these five trials, rates of IV replacement were lower in the preoperative supplementation group. CONCLUSION: The use of preoperative Vitamin D, with or without calcium, may provide a modest reduction in the incidence of laboratory and clinic hypocalcaemia following total or near total thyroidectomy. There is a trend toward a reduced requirement for IV calcium with preoperative supplementation. Larger robust randomised trials are needed to provide a definitive answer. Preoperative supplementation can be considered in patients undergoing total or near total thyroidectomy.

Prediction of long-term dependence on vitamin D analogues following total thyroidectomy for Graves' disease.

INTRODUCTION: This study aimed to identify patients at risk of long-term hypocalcaemia following total thyroidectomy for Graves' disease, and to determine the thresholds of postoperative day 1 serum calcium and parathyroid hormone (PTH) at which long-term activated vitamin D treatment can be safely excluded. METHODS: This study was a retrospective analysis of 115 consecutive patients undergoing total thyroidectomy for Graves' disease at a university referral centre between 2010 and 2018. Outcome measures were the day 1 postoperative adjusted calcium and PTH results, and vitamin D analogue need at 6 months postoperatively. Logistic receiver operating curves were used to identify optimal cut-off values for adjusted serum calcium and serum PTH, and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: Temporary hypocalcaemia was observed in 20.9% of patients (mean day 1 serum adjusted calcium 2.2±0.14mmol/l and PTH 4.15±2.42pmol/l). Long-term (>6 months) activated vitamin D analogue therapy was required in five patients (4.3%), four of whom had normal serum PTH and one with undetectable PTH at 6 weeks post surgery. No patient with a day 1 postoperative calcium >2.05mmol/l and detectable PTH required vitamin D supplementation at 6 months post surgery (100% sensitivity, PPV 50%, NPV 100%). CONCLUSIONS: The biochemical postoperative day 1 thresholds identified in this paper have a 100% NPV in the identification of patients who are likely to require either no or only temporary activated vitamin D supplementation. We were able to identify all patients requiring activated vitamin D supplementation 6 months postoperatively from the day 1 postoperative serum calcium and PTH values, while excluding those that may only need temporary calcium supplementation. These threshold levels could be used for targeted follow-up and management of this subset of patients most at risk of long-term hypocalcaemia.

Health-Related Quality of Life following Total Thyroidectomy and Lobectomy for Differentiated Thyroid Carcinoma: A Systematic Review.

Health-related quality of life (HrQoL) is a major concern for patients with differentiated thyroid carcinoma (DTC). We aimed to systematically review the literature comparing HrQol following total thyroidectomy (TT) and hemithyroidectomy (HT) in DTC patients. A systematic review of publications indexed in Medline, Embase, and EBM reviews-Cochrane Central Register of Controlled Trials, which evaluated HrQoL following thyroid surgery for DTC, was conducted. Of 2507 identified records, 25 fulfilled the inclusion criteria. Our results suggest that patients undergoing TT may suffer more impairment in physical and social HrQoL than patients undergoing HT. Psychological-related HrQoL and long-term global HrQoL are, however, equivalent in both groups, which highlights the multidimensional nature of HrQoL and the importance of a multitude of factors aside from treatment modalities and related morbidities, such as the experience of receiving a cancer diagnosis, the fear of cancer recurrence, and other psychosocial factors. Addressing postoperative HrQoL when discussing therapeutic options with patients is an integral part of patient-centered care and informed shared decision-making, and should be approached in a holistic manner, accounting for its physical, psychological, and social aspects. This review supplies evidence regarding HrQoL following thyroid surgery, which can be employed in such decisions.

Outcomes of Papillary Thyroid Microcarcinoma Presenting with Palpable Lateral Lymphadenopathy.

Purpose: Papillary thyroid microcarcinoma (PTMC) is typically indolent in nature, allowing management with active surveillance protocols. Occasionally, a more aggressive phenotype can present and may lead to poor outcomes such as patients presenting with clinically significant lateral lymphadenopathy (cN1b). Prior analysis of the outcomes of this cohort is largely from papillary thyroid cancer (PTC) (>1 cm) or from institutions where use of radioactive iodine (RAI) is limited. Hence, we aim to describe the outcomes of patients with PTMC who presented with palpable cN1b disease, treated with total thyroidectomy and RAI. Methodology: We performed a retrospective cohort study. Outcomes of patients with PTMC who presented with palpable lateral lymph node (LN) metastases (microPTC cN1b) treated between 1997 and 2020 at Royal North Shore Hospital were compared with two control groups' outcomes: patients with clinically detected PTMC without evidence of involved LNs (microPTC cN0) and with larger PTC (>10 mm) who presented with palpable lateral lymphadenopathy (larger PTC cN1b). We assessed clinicopathological variables, postoperative risk stratification, rates of disease recurrence, reoperative surgery, and structural disease-free survival (DFS). Results: In total, 1534 PTMCs were diagnosed following thyroid surgery in the study period; of these, 157 (10%) were clinically detected microPTC cN0 and 26 microPTC cN1b (1.7%). There were 138 patients in the larger PTC cN1b control group. All cN1b patients were treated with total thyroidectomy and adjuvant RAI. Mean size of the largest LN deposit was similar between the microPTC cN1b and larger PTC cN1b groups (23 vs. 27 mm, p = 0.11). Patients with microPTC cN1b were more likely to have biochemical or structural persistence or recurrence compared with microPTC cN0 (19%, 5/26 vs. 3.8%, 6/157, p = 0.002) but less likely than larger PTC cN1b patients (19%, 5/26 vs. 42%, 58/138, p = 0.04). All patients in the microPTC cN1b group who had an excellent response to initial therapy (85%, 22/26) were disease free at last follow-up. The rate of reoperation was similar for the microPTC cN1b and microPTC cN0 groups (4%, 1/26 vs. 2%, 3/157, p = 0.461) and significantly lower than the larger PTC cN1b group (4%, 1/26 vs. 26%, 36/138, p = 0.002). Five-year DFS estimates were significantly better for microPTC cN1b patients than for larger PTC cN1b patients (94% vs. 59%, p = 0.001). Conclusions: MicroPTC cN1b patients treated with thyroidectomy and adjuvant RAI have inferior clinical outcomes compared with microPTC cN0 patients but have better outcomes than their larger PTC cN1b counterparts with respect to disease persistence and recurrence. Response to initial therapy provides valuable prognostication in microPTC cN1b patients: if these patients had an excellent response to initial treatment, they achieved long-term DFS in this series.

Lymph Node Dissection for Papillary Thyroid Carcinoma.

Cervical lymph node metastasis is frequent in patients with papillary thyroid carcinoma. In addition to the extent of thyroidectomy, the need as well as the extent of concomitant lymphadenectomy has been a subject of controversy and debate. The central compartment is the most frequent site of metastasis followed by the lateral compartment although skip metastasis in the lateral compartment can occur. Papillary thyroid carcinoma can also present with cervical lymph node metastasis, while the primary tumor remains clinically undetectable. Surgical removal of clinically involved nodal metastasis should be mandatory to prevent recurrence and improve disease prognosis. However, despite a low accuracy of preoperative imaging for microscopic disease and the frequent microscopic metastasis to the central compartment, routine prophylactic neck dissection has not been shown to have any relevance to prevent recurrence or improve disease cure. Routine or prophylactic central compartment dissection is generally not recommended unless in the presence of high-risk tumors. The potential benefit of reducing central compartment recurrence or avoiding high-risk reoperation probably outweighs the risk of inducing surgical complication including hypoparathyroidism during routine central neck dissection. Therapeutic lateral neck dissection is performed for clinically involved nodes detected by preoperative imaging confirmed by needle biopsy, while prophylactic lateral neck dissection is contraindicated. The extent of neck dissection has been de-escalated, and compartmental nodal dissection aiming at preservation of function is performed to achieve a complete surgical resection. Postoperative adjuvant radioiodine is frequently administered for patients with positive nodal metastasis (intermediate-risk group) to avoid future recurrence. Routine central neck dissection may also upstage patients with microscopic nodal metastases and increase the use of postoperative adjuvant radioiodine.

Diagnosis and treatment of thyroid cancer in adult patients - Recommendations of Polish Scientific Societies and the National Oncological Strategy. 2022 Update [Diagnostyka i leczenie raka tarczycy u chorych doroslych - Rekomendacje Polskich Towarzystw Naukowych oraz Narodowej Strategii Onkologicznej. Aktualizacja na rok 2022].

The guidelines Thyroid Cancer 2022 are prepared based on previous Polish recommendations updated in 2018. They consider international guidelines - American Thyroid Association (ATA) 2015 and National Comprehensive Cancer Network (NCCN); however, they are adapted according to the ADAPTE process. The strength of the recommendations and the quality of the scientific evidence are assessed according to the GRADE system and the ATA 2015 and NCCN recommendations. The core of the changes made in the Polish recommendations is the inclusion of international guidelines and the results of those scientific studies that have already proven themselves prospectively. These extensions allow de-escalation of the therapeutic management in low-risk thyroid carcinoma, i.e., enabling active surveillance in papillary microcarcinoma to be chosen alternatively to minimally invasive techniques after agreeing on such management with the patient. Further extensions allow the use of thyroid lobectomy with the isthmus (hemithyroidectomy) in low-risk cancer up to 2 cm in diameter, modification of the indications for postoperative radioiodine treatment toward personalized approach, and clarification of the criteria used during postoperative L-thyroxine treatment. At the same time, the criteria for the preoperative differential diagnosis of nodular goiter in terms of ultrasonography and fine-needle aspiration biopsy have been clarified, and the rules for the histopathological examination of postoperative thyroid material have been updated. New, updated rules for monitoring patients after treatment are also presented. The updated recommendations focus on ensuring the best possible quality of life after thyroid cancer treatment while maintaining the good efficacy of this treatment.

Immunomodulatory Effects of Omega-3 Fatty Acids in Patients with Differentiated Thyroid Cancer Before or After Radioiodine Ablation.

BACKGROUND: Thyroid cancer and radioactive iodine (RAI) ablation for postsurgical management may lead to uncontrolled inflammation. OBJECTIVE: This study was intended to assess the prophylactic and therapeutic immunomodulatory effects of omega-3 fatty acids in patients with differentiated thyroid cancer (DTC). METHODS: A total of 85 patients with DTC were allocated into two groups based on RAI dosage after thyroidectomy. Patients in each group were randomly distributed into three subgroups: G1 with RAI ablation only, G2 treated with omega-3 for 30 days before RAI ablation, and G3 treated with omega-3 for 30 days after RAI ablation. Fifteen healthy individuals were included as controls. Serum cytokine levels including IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-13, IL-17A, IL-17F, IL-21, IL-22, TNF-α and IFN-γ were determined by cytometric bead assay. RESULTS: IL-4, IL-6, IL-21 and IL-22 levels in patients with DTC were higher than in the healthy controls. Regardless of RAI dosage, IL-6 showed an increasing trend after RAI ablation. IL-4, IL-22, and IL-17A remained at considerably higher levels than in the healthy controls after RAI ablation. Within-group comparisons showed a significant reduction in Th1+Th17/Th2+Th22 ratio in G2 patients 1 week after RAI ablation. Between-group comparisons showed increased IL-10 levels in G3 compared with G1 patients one week after high-dose RAI ablation. In G3, Th1+Th17/Th2+Th22 and Th1+Th17/Th2+Th9+Th22 ratios were remarkably lesser than in G2 patients 1 month after intermediate-dose RAI ablation. CONCLUSION: Our results showed better anti-inflammatory effects of omega-3 when it was used therapeutically after RAI ablation in patients with DTC than when it was used prophylactically before RAI.

Incidental Parathyroidectomy Among Pediatric Patients Undergoing Thyroid Surgery.

OBJECTIVE: To evaluate rates of incidental parathyroidectomy(IP) and to determine risk factors among children undergoing thyroid surgery. STUDY DESIGN: Retrospective case-control study. METHODS: Pediatric patients undergoing thyroidectomy with or without neck dissection were included in this retrospective cohort study over a 20 year period. Demographics, clinical features, and surgical outcomes were evaluated. The primary outcome was the presence of parathyroid tissue in the surgical specimen. RESULTS: Two hundred and eighty-six patients were included (100 cases with ≥1 parathyroid gland found in the pathology specimen and 186 controls). The most common surgical indication was cancer (49%), followed by benign nodule (25%). Hemithyroidectomy was performed in 119 (42%) patients, total thyroidectomy in 138 (48%), and completion in 29 (10%). Central neck dissection (CND) and lateral neck dissection were performed in 41% and 13%, respectively. 27 (9%) patients had parathyroid reimplantation. On univariable analysis, diagnosis, adenopathy on preoperative ultrasound, extent of thyroidectomy, neck dissection, and parathyroid reimplantation were significant predictors of IP. On multivariate analysis, CND > 5 nodes were the sole predictor of IP. Patients with IP were more likely to require postoperative calcium/vitamin D supplementation compared to those without (44% vs. 16%; P < .001). CONCLUSIONS: Incidental parathyroidectomy during pediatric thyroidectomy is relatively common. CND was independently predictive of IP. There were increased rates of postoperative hypocalcemia when 1 or more parathyroid gland was identified in the specimen. Reimplantation of 1 parathyroid gland was predictive of another gland in the specimen. Anticipating outcomes may help optimize patient care by allowing for early supplementation, frequent monitoring, and consideration of ancillary monitoring modalities in high-risk procedures. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 132:2262-2269, 2022.

Thyroidectomy with and without laryngectomy: Differences in post-operative hypocalcemia and management.

BACKGROUND: Total laryngectomy (TL) with thyroidectomy can pose significant risks to parathyroid function, and variance in rates of post-operative hypocalcemia (POH) based on extent of thyroidectomy have not been previously reported. Our objective is to identify the rates of hypocalcemia and hypoparathyroidism in TL+/-thyroidectomy and compare this to matched thyroidectomy alone cohorts. METHODS: Multi-institutional retrospective chart review of patients treated surgically for laryngeal cancer with TL or benign/malignant thyroid disease with thyroidectomy at regional tertiary care centers in New Orleans and Baton Rouge, Louisiana from 2016 to 2019. Cases were evaluated for post-operative and post-discharge calcium and parathyroid hormone levels, post-operative and long-term calcium supplementation, and intraoperative parathyroid identification and management. RESULTS: 101 TL and 319 thyroidectomy patients' charts were reviewed. Regression analysis revealed increased odds of hypocalcemia and hypoparathyroidism in TL + TT versus TT alone (OR 10.7, OR 16.5, p < 0.001, respectively). TL + HT versus HT alone had increased odds of hypoparathyroidism (OR 1.6, p < 0.001). TL with any thyroidectomy compared to TL alone demonstrated both increased odds of hypocalcemia and hypoparathyroidism (OR 4.4 p = 0.009, and OR 4.5 p = 0.05). Odds of requiring long-term calcium supplementation were significantly increased with the addition of thyroidectomy across all groups. TL + TT was 8 times as likely (p = 0.002) and TL + HT was 5.3 times as likely (p = 0.001) to require long-term calcium supplementation compared to TL alone. CONCLUSIONS: Thyroidectomy combined with TL demonstrates marked increased risk of parathyroid dysfunction and resultant POH. Despite improved visualization of soft tissue anatomy with TL, risk of parathyroid injury in these settings requires special attention to extent of parathyroid dissection and potential devascularization to reduce long-term sequelae of hyperparathyroidism. Therefore, post-operative calcium monitoring after TL is necessary and should resemble the long-standing stringent protocols that already exist for monitoring in thyroidectomy populations.

Overall survival is improved with total thyroidectomy and radiation for male patients and patients older than 55 with T2N0M0 Stage 1 classic papillary thyroid cancer.

BACKGROUND: We examine whether surgery extent and radiation administration affect overall survival for cT2N0M0 classic papillary thyroid cancer according to age and sex. METHODS: Patients with cT2N0M0 classic papillary thyroid cancer tumors in the National Cancer Data Base (2004-2016) were selected. Multivariable Cox regression analysis compared patients (combined male + female cohorts) having lobectomy to those having total thyroidectomy with or without radiation (primarily radioactive iodine) for ages: 18 to 45, 46 to 55, and >55 years. In addition, 1:1 propensity score matching and Kaplan-Meier curves with 10-year overall survival estimates, and log-rank test were stratified by age and sex. RESULTS: Lobectomy had equivalent overall survival to total thyroidectomy without and with radiation for patients (combined male + female cohorts) aged 18 to 45 and 46 to 55 years on multivariable analysis. On propensity score matching there was overall survival advantage for total thyroidectomy with radiation over both lobectomy and total thyroidectomy for men (ages 18-90+ combined) and overall survival advantage in patients (combined male + female cohort) aged >55 years having total thyroidectomy with radiation versus lobectomy. On propensity score matching there were no overall survival differences in women (ages 18-90+ combined) or patients (combined male + female cohort) aged 18 to 45 and 46 to 55 years having either lobectomy, total thyroidectomy, or total thyroidectomy with radiation. CONCLUSION: For cT2N0M0 classic papillary thyroid cancer, total thyroidectomy with radiation improves 10-year overall survival for patients (combined male + female cohort) aged >55 years and men (ages 18-90+ combined).

Variations in Radioiodine Therapy in Europe: Decision-Making after Total Thyroidectomy.

The role of radioiodine therapy (RIT) (used as ablation therapy or adjuvant therapy) following total thyroidectomy for differentiated thyroid cancer (DTC) changed. Major revisions of the American Thyroid Association (ATA) Guidelines in 2015 resulted in significant differences in treatment recommendations in comparison to the European Association of Nuclear Medicine (EANM) 2008 guidelines. Recently, we presented the effects on daily practice for RIT among Swiss Nuclear Medicine centres. We now performed a study at the European level and hypothesized that there is also considerable variability among European experts. We performed a decision-tree-based analysis of management strategies from all members of the EANM thyroid committee to map current practice among experts. We collected data on whether or not RIT is administered, on which criteria these decisions are based and collected details on treatment activities and patient preparation. Our study shows discrepancies for low-risk DTC, where "follow-up only" is recommended by some experts, while RIT with significant doses is used by other experts. E.g., for pT1b tumours without evidence of metastases, the level of agreement for the use of RIT is as low as 50%. If RIT is administered, activities of I-131 range from 1.1 GBq to 3.0 GBq. In other constellations (e.g., pT1a), experts diverge from current clinical guidelines as up to 75% administer RIT in certain cases. For intermediate and high-risk patients, RIT is generally recommended. However, dosing and treatment preparation (rhTSH vs. thyroid hormone withdrawal) vary distinctly. In comparison to the Swiss study, the general level of agreement is higher among the European experts. The recently proposed approach on the use of RIT, based on integrated post-surgery assessment (Martinique article) and results of ongoing prospective randomized studies are likely to reduce uncertainty in approaching RIT treatment. In certain constellations, consensus identified among European experts might be helpful in formulating future guidelines.