Changes in Clinical Practice in Adherence to the 2014 American Thyroid Association Guidelines on Thyroid Cancer: A Retrospective Study from a Tertiary Referral Center.

Thyroidectomy, a pivotal treatment for various thyroid disorders, has seen its indications evolve, particularly with the 2014 American Thyroid Association (ATA) Guidelines advocating for conservative surgical approaches like lobectomy. This retrospective study analyzes thyroidectomy practices at a high-volume center from January 2014 to December 2023, focusing on patients potentially eligible for lobectomy per ATA guidelines. The inclusion criteria were tumors < 4 cm, indeterminate thyroid nodules, or differentiated thyroid carcinoma with clinically uninvolved lymph nodes (cN0). This study analyzed the proportion of patients undergoing lobectomy versus total thyroidectomy (TT) and the oncological outcomes. Of 357 patients, 243 underwent TT and 114 underwent lobectomy. The prevalence of lobectomies rose markedly, comprising 73.9% of surgeries in 2023. TT patients were predominantly female (83.5%) and had higher rates of autoimmune thyroiditis (67.5%) and malignancy (89.7%). Lobectomy patients had larger nodules and more indeterminate cytology. Among 301 malignant cases, TT was associated with higher lymph node metastasis, but similar recurrence rates, compared to lobectomy. This study underscores a shift towards lobectomy, reflecting adherence to ATA guidelines and suggesting conservative surgery is feasible without compromising outcomes. Further research on long-term outcomes and refined patient selection criteria is needed to optimize surgical approaches.

Exploring the Link between BMI and Aggressive Histopathological Subtypes in Differentiated Thyroid Carcinoma-Insights from a Multicentre Retrospective Study.

Obesity's role in thyroid cancer development is still debated, as well as its association with aggressive histopathological subtypes (AHSs). To clarify the link between Body Mass Index (BMI) and AHS of differentiated thyroid carcinoma (DTC), we evaluated patients who underwent thyroidectomy for DTC from 2020 to 2022 at four European referral centres for endocrine surgery. Based on BMI, patients were classified as normal-underweight, overweight, or obese. AHSs were defined according to 2022 WHO guidelines. Among 3868 patients included, 34.5% were overweight and 19.6% obese. Histological diagnoses were: 93.6% papillary (PTC), 4.8% follicular (FTC), and 1.6% Hürthle cell (HCC) thyroid carcinoma. Obese and overweight patients with PTC had a higher rate of AHSs (p = 0.03), bilateral, multifocal tumours (p = 0.014, 0.049), and larger nodal metastases (p = 0.017). In a multivariate analysis, BMI was an independent predictor of AHS of PTC, irrespective of gender (p = 0.028). In younger patients (<55 years old) with PTC > 1 cm, BMI predicted a higher ATA risk class (p = 0.036). Overweight and obese patients with FTC had larger tumours (p = 0.036). No difference was found in terms of AHS of FTC and HCC based on BMI category. Overweight and obese patients with PTC appear to be at an increased risk for AHS and aggressive clinico-pathological characteristics.

Differences in surgical outcomes between cervical goiter and retrosternal goiter: an international, multicentric evaluation.

Introduction: Goiter is a common problem in clinical practice, representing a large part of clinical evaluations for thyroid disease. It tends to grow slowly and progressively over several years, eventually occupying the thoracic inlet with its lower portion, defining the situation known as retrosternal goiter. Total thyroidectomy is a standardized procedure that represents the treatment of choice for all retrosternal goiters, but when is performed for such disease, a higher risk of postoperative morbidity is variously reported in the literature. The aims of our study were to compare the perioperative and postoperative outcomes in patients with cervical goiters and retrosternal goiters undergoing total thyroidectomy. Methods: In our retrospective, multicentric evaluation we included 4,467 patients, divided into two groups based on the presence of retrosternal goiter (group A) or the presence of a classical cervical goiter (group B). Results: We found statistically significant differences in terms of transient hypoparathyroidism (19.9% in group A vs. 9.4% in group B, p < 0.001) and permanent hypoparathyroidism (3.3% in group A vs. 1.6% in group B, p = 0.035). We found no differences in terms of transient RNLI between group A and group B, while the occurrence of permanent RLNI was higher in group A compared to group B (1.4% in group A vs. 0.4% in group B, p = 0.037). Moreover, no differences in terms of unilateral RLNI were found, while bilateral RLNI rate was higher in group A compared to group B (1.1% in group A vs. 0.1% in group B, p = 0.015). Discussion: Wound infection rate was higher in group A compared to group B (1.4% in group A vs. 0.2% in group B, p = 0.006). Based on our data, thyroid surgery for retrosternal goiter represents a challenging procedure even for highly experienced surgeons, with an increased rate of some classical thyroid surgery complications. Referral of these patients to a high-volume center is mandatory. Also, intraoperative nerve monitoring (IONM) usage in these patients is advisable.

Diffuse C-Cells Hyperplasia Is the Source of False Positive Calcitonin Measurement in FNA Washout Fluids of Thyroid Nodules: A Rational Clinical Approach to Avoiding Unnecessary Surgery.

PURPOSE: The FNA-CT is useful for the diagnosis of MTC. The aim of this study was to evaluate the performance of FNA-CT in TNs coexisting with CCH. METHODS: This study retrospectively reviewed the records of 11 patients with TNs submitted to thyroidectomy on the basis of elevated basal and/or stimulated serum CT values, which at histology were not confirmed to be MTC. The results obtained in this group were compared with those of a previously reported group of histologically proven MTC patients submitted to an identical presurgical evaluation. All patients, negative for known mutations in the RET proto-oncogene, were preoperatively submitted to neck ultrasound, FNA-cytology, and FNA-CT. RESULTS: Approximately 6 of 11 patients showed increased (>36 ng/mL, as established in previous studies not involving patients with CCH) FNA-CT. All these patients showed diffuse CCH at histology in the thyroid lobe submitted to FNA; 5 of them were benign at histology, while only one was malignant (papillary thyroid carcinoma, PTC). The remaining 5 of 11 patients had low FNA-CT (<36 ng/mL), and all of them showed only focal CCH in the lobe submitted to FNA; three of them were malignant (2 PTC, 1 follicular carcinoma), while two were benign. CONCLUSIONS: Employing the currently proposed cut-off values, false-positive FNA-CT results may be observed in benign/malignant TNs with coexisting diffuse CCH. FNA-CT must therefore be cautiously used in the diagnostic approach for patients with TNs and a slightly increased basal or stimulated serum CT concentration in order to avoid unnecessary surgery.

Risk factors for postoperative cervical haematoma in patients undergoing thyroidectomy: a retrospective, multicenter, international analysis (REDHOT study).

Background: Postoperative cervical haematoma represents an infrequent but potentially life-threatening complication of thyroidectomy. Since this complication is uncommon, the assessment of risk factors associated with its development is challenging. The main aim of this study was to identify the risk factors for its occurrence. Methods: Patients undergoing thyroidectomy in seven high-volume thyroid surgery centers in Europe, between January 2020 and December 2022, were retrospectively analysed. Based on the onset of cervical haematoma, two groups were identified: Cervical Haematoma (CH) Group and No Cervical Haematoma (NoCH) Group. Univariate analysis was performed to compare these two groups. Moreover, employing multivariate analysis, all potential independent risk factors for the development of this complication were assessed. Results: Eight thousand eight hundred and thirty-nine patients were enrolled: 8,561 were included in NoCH Group and 278 in CH Group. Surgical revision of haemostasis was performed in 70 (25.18%) patients. The overall incidence of postoperative cervical haematoma was 3.15% (0.79% for cervical haematomas requiring surgical revision of haemostasis, and 2.35% for those managed conservatively). The timing of onset of cervical haematomas requiring surgical revision of haemostasis was within six hours after the end of the operation in 52 (74.28%) patients. Readmission was necessary in 3 (1.08%) cases. At multivariate analysis, male sex (P < 0.001), older age (P < 0.001), higher BMI (P = 0.021), unilateral lateral neck dissection (P < 0.001), drain placement (P = 0.007), and shorter operative times (P < 0.001) were found to be independent risk factors for cervical haematoma. Conclusions: Based on our findings, we believe that patients with the identified risk factors should be closely monitored in the postoperative period, particularly during the first six hours after the operation, and excluded from outpatient surgery.

Surgical Management of Indeterminate Thyroid Nodules across Different World Regions: Results from a Retrospective Multicentric (the MAIN-NODE) Study.

Indeterminate thyroid nodules (ITNs) are characterized by an expected malignancy ranging from 5% to 30%, with most patients undergoing a diagnostic, rather than therapeutic, operation. The aim of our study was to compare the approach to ITNs across different regions of the world. In this retrospective, multicentric, international study, according to the WHO classification, we identified the South East Asian Region (SEAR), the Americas Region (AMR), the Eastern Mediterranean Region (EMR), the Europe Region (EUR), and the Western Pacific Region (WPR). One high-volume thyroid centre was included for each region. Demographic, preoperative, and pathologic data were compared among the different regions. Overall, 5737 patients from five high-volume thyroid centres were included in this study. We found that the proportion of ITNs over the global activity for thyroid disease was higher in the EUR (37.6%) than in the other regions (21.1-23.6%). In the EMR, the patients were significantly younger (with a mean of 43.1 years) than in the other regions (range, 48.8-57.4 years). The proportion of lobectomy was significantly higher in the WPR, where 83.2% (114/137) of patients received this treatment, than in the other regions, where lobectomies were performed in 44.1-58.1% of patients. The pathological diagnosis of malignancy was significantly higher in the SEAR centre, being over 60%, than in centres of the other regions, where it ranged from 26.3% to 41.3%. The occurrence of lymph node metastases was higher in the WPR (27.8%), AMR (26.9%), and EMR (20%) centres than in the EUR and SEAR centres, where it was lower than 10%. In summary, we found in our study different approaches and outcomes in the diagnosis and treatment of ITNs among countries. Overall, almost 60% of patients with ITNs who underwent surgery actually presented a benign disease, potentially undergoing an unnecessary operation.

US Evaluation of Topical Hemostatic Agents in Post-Thyroidectomy.

BACKGROUND: the aim of this study was to describe the ultrasound appearance of topical hemostatics after thyroidectomy. METHODS: we enrolled 84 patients who were undergoing thyroid surgery and were treated with two types of topical hemostats, 49 with an absorbable hemostat of oxidized regenerated cellulose (Oxitamp®) and 35 with a fibrin glue-based hemostat (Tisseel®). All patients were examined using B-mode ultrasound. RESULTS: In 39 patients of the first group (approximately 80%), a hemostatic residue was detected and in some cases confused with a native gland residue, or with cancer recurrence in oncological patients. No residue was detected in patients in the second group. The main ultrasound characteristics of the tampon were analyzed and arranged according to predefined patterns, and suggestions to recognize it and avoid wrong diagnoses were provided. A part of the group of patients with tampon residue was re-evaluated after 6-12 months, ensuring that the swab remained for months after the maximum resorption time declared by the manufacturer. CONCLUSIONS: with equal hemostatic effectiveness, the fibrin glue pad is more favorable in the ultrasound follow-up because it creates reduced surgical outcomes. It is also important to know and recognize the ultrasound characteristics of oxidized cellulose-based hemostats in order to reduce the number of diagnostic errors and inappropriate diagnostic investigations.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study.

BACKGROUND: Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours. METHODS: In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186. FINDINGS: Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039). INTERPRETATION: Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation. FUNDING: None.

Axillary Treatment Management in Breast Cancer during COVID-19 Pandemic (Association between ACOSOG Z0011 Criteria and OSNA Test).

The outbreak of the SARS-COVID-2 pandemic (COVID-19) had a significant effect on the organisation of healthcare systems. Surgical units saw a significant reduction in the volume of surgical procedures performed, with lengthening waiting lists as a consequence. We assessed the surgical activity in relation to breast cancer that took place at the University Hospital of Cagliari, Italy, from February 2018 to March 2022. Two phases were identified based on the epidemiological circumstances: Phase 1-February 2018 to February 2020; Phase 2-March 2020 to March 2022. The surgery performed in the two phases was then compared. All the patients in our sample underwent a breast surgical procedure involving a lymph node biopsy using OSNA associated with the ACOSOG Z0011 criteria. In the study period overall at our facility, there were 4214 procedures, 417 of which involved breast surgery. In Phase 2, 91 procedures were performed using the OSNA method and ACOSOG Z0011 criteria, enabling the intraoperative staging of axillary nodes. Axillary treatment in breast cancer using this approach resulted in a significant reduction in the number of reoperations for the radicalisation of metastatic sentinel lymph nodes.

The paradox of Zeno in bariatric surgery weight loss: Superobese patients run faster than morbidly obese patients, but can't overtake them.

Introduction: Superobesity (SO) is defined as a BMI > 50 Kg/m2, and represents the extreme severity of the disease, resulting in a challenge for the surgeons. Methods: In this retrospective study we aimed to compare the outcomes of SO patients compared to morbidly obese (MO) patients. Results: We included in this study 154 MO patients, with a median preoperative BMI of 40.8 kg/m2, and 19 SO patients with median preoperative BMI of 54.9 kg/m2. The MO patients underwent sleeve gastrectomy (SG) in 62 (40.3%) cases, laparoscopic Roux-and-Y gastric bypass (LRYGBP) in 85 (55.2%) cases and One-Anastomosis Gastric Bypass (OAGB) in 7 (4.5%) cases. underwent OAGB. The patients in the SO group were submitted to SG in 11 (57.9%) cases, LRYGBP in 5 (26.3%) cases, and OAGB in 3 (15.8%). At 24-month follow-up, an excess weight loss (EWL) >50% was achieved in 129 (83.8%) patients in the MO group and in 15 (78.9%) in the SO group (p = 0.53). A BMI < 35 kg/m2 was achieved in 137 (89%) patients in the MO group and from 8 (42.2%) patients in the SO group (p < 0.001). The total weight loss was significantly directly related to the initial BMI. Superobesity was identified as independent risk factor for surgical failure when considering the outcome of BMI < 35 kg/m2. Discussion: Our study confirms that, although SO patients tend to gain a greater weight loss than MO patients, they less frequently achieve the desired BMI target. In this setting, it should be necessary to re-consider malabsorptive procedures as first choice.

Does the continuation of low-dose acetylsalicylic acid during the perioperative period of thyroidectomy increase the risk of cervical haematoma? A 1-year experience of two Italian centers.

Background: A growing number of patients taking antiplatelet drugs, mainly low-dose acetylsalicylic acid (ASA) (75-150 mg/day), for primary or secondary prevention of thrombotic events, are encountered in every field of surgery. While the bleeding risk due to the continuation of these medications during the perioperative period has been adequately investigated in several surgical specialties, in thyroid surgery it still needs to be clarified. The main aim of this study was to assess the occurrence of cervical haematoma in patients receiving low-dose acetylsalicylic acid, specifically ASA 100 mg/day, during the perioperative period of thyroidectomy. Methods: Patients undergoing thyroidectomy in two high-volume thyroid surgery centers in Italy, between January 2021 and December 2021, were retrospectively analysed. Enrolled patients were divided into two groups: those not taking ASA were included in Group A, while those receiving this drug in Group B. Univariate analysis was performed to compare these two groups. Moreover, multivariate analysis was employed to evaluate the use of low-dose ASA as independent risk factor for cervical haematoma. Results: A total of 412 patients underwent thyroidectomy during the study period. Among them, 29 (7.04%) were taking ASA. Based on the inclusion criteria, 351 patients were enrolled: 322 were included in Group A and 29 in Group B. In Group A, there were 4 (1.24%) cervical haematomas not requiring surgical revision of haemostasis and 4 (1.24%) cervical haematomas requiring surgical revision of haemostasis. In Group B, there was 1 (3.45%) cervical haematoma requiring surgical revision of haemostasis. At univariate analysis, no statistically significant difference was found between the two groups in terms of occurrence of cervical haematoma, nor of the other early complications of thyroidectomy. At multivariate analysis, the use of low-dose ASA did not prove to be an independent risk factor for cervical haematoma. Conclusions: Based on our findings, we believe that in patients receiving this drug, either for primary or secondary prevention of thrombotic events, its discontinuation during the perioperative period of thyroidectomy is not necessary.

Association between hashimoto thyroiditis and differentiated thyroid cancer: A single-center experience.

Hashimoto's thyroiditis is the most common cause of hypothyroidism in the iodine-sufficient areas of the world. Differentiated thyroid cancer is the most common thyroid cancer subtype, accounting for more than 95% of cases, and it is considered a tumor with a good prognosis, although a certain number of patients experience a poor clinical outcome. Hashimoto's thyroiditis has been found to coexist with differentiated thyroid cancer in surgical specimens, but the relationship between these two entities has not yet been clarified. Our study aims to analyze the relationship between these two diseases, highlighting the incidence of histological diagnosis of Hashimoto thyroiditis in differentiated thyroid cancer patients, and assess how this autoimmune disorder influences the risk of structural disease recurrence and recurrence rate.

The Use of Harmonic Focus and Thunderbeat Open Fine Jaw in Thyroid Surgery: Experience of a High-Volume Center.

Background: In thyroid surgery, achieving accurate haemostasis is fundamental in order to avoid the occurrence of complications. Energy-based devices are currently extensively utilized in this field of surgery. This study aims to compare Harmonic Focus and Thunderbeat Open Fine Jaw with regard to surgical outcomes and complications. Methods: Patients submitted to total thyroidectomy in our center, between January 2017 and June 2020, were retrospectively analysed. Based on the energy-based device utilized, two groups were identified: Group A (Harmonic Focus) and Group B (Thunderbeat Open Fine Jaw). Results: A total of 527 patients were included: 409 in Group A and 118 in Group B. About surgical outcomes, the mean operative time was significantly shorter in Group B than in Group A (p < 0.001), while as regards complications, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in Group B than in Group A (p = 0.019). Conclusions. Both Harmonic Focus and Thunderbeat Open Fine Jaw have proven to be effective devices. Operative times were significantly shorter in thyroidectomies performed with Thunderbeat Open Fine Jaw; however, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in patients operated on with this device.

Risk of Complications in Patients Undergoing Completion Thyroidectomy after Hemithyroidectomy for Thyroid Nodule with Indeterminate Cytology: An Italian Multicentre Retrospective Study.

There is still controversy as to whether patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology have a comparable, increased or decreased risk of complications compared to those submitted to primary thyroid surgery. The main aim of this study was to investigate this topic. Patients undergoing a thyroidectomy for thyroid nodular disease with an indeterminate cytology in four high-volume thyroid surgery centres in Italy, between January 2017 and December 2020, were retrospectively analysed. Based on the surgical procedure performed, four groups were identified: the TT Group (total thyroidectomy), HT Group (hemithyroidectomy), CT Group (completion thyroidectomy) and HT + CT Group (hemithyroidectomy with subsequent completion thyroidectomy). A total of 751 patients were included. As for the initial surgery, 506 (67.38%) patients underwent a total thyroidectomy and 245 (32.62%) a hemithyroidectomy. Among all patients submitted to a hemithyroidectomy, 66 (26.94%) were subsequently submitted to a completion thyroidectomy. No statistically significant difference was found in terms of complications comparing both the TT Group with the HT + CT Group and the HT Group with the CT Group. The risk of complications in patients undergoing a completion thyroidectomy after a hemithyroidectomy for a thyroid nodule with an indeterminate cytology was comparable to that of patients submitted to primary thyroid surgery (both a total thyroidectomy and hemithyroidectomy).

Intact parathyroid hormone value on the first postoperative day following total thyroidectomy as a predictor of permanent hypoparathyroidism: a retrospective analysis on 426 consecutive patients.

INTRODUCTION: Hypoparathyroidism represents a common complication following total thyroidectomy. To date, there is still no reliable and immediate postoperative parameter to establish which patients with postsurgical hypoparathyroidism will develop permanent hypoparathyroidism. The main purpose of the present study was to assess whether the intact parathyroid hormone (iPTH) value on the first postoperative day is a good predictor of permanent hypoparathyroidism. MATERIAL AND METHODS: Patients undergoing thyroidectomy in our unit between March 2018 and January 2020 were analysed. According to the iPTH value on the first postoperative day and on the basis of the detection threshold of the iPTH test used, patients were divided into two groups: Group A (iPTH ≥ 4.6 pg/mL) and Group B (iPTH < 4.6 pg/mL, undetectable). RESULTS: In total 426 patients were included: 364 in Group A and 62 in Group B. Permanent hypoparathyroidism occurred in 3 (0.82%) patients from Group A and in 26 (41.94%) from Group B (p < 0.001). When iPTH levels were < 4.6 pg/mL on the first postoperative day the sensitivity for the prediction of permanent hypoparathyroidism was 89.66%, the specificity was 90.93%, the positive predictive value (PPV) was 41.94%, the negative predicitive value (NPV) was 99.18% and the accuracy was 90.85%. CONCLUSIONS: An iPTH value < 4.6 pg/mL on the first postoperative day following total thyroidectomy has proven to be a good parameter for early identification of patients at high risk for permanent hypoparathyroidism. Moreover, we want to underline that in our experience no patient with an iPTH level > 6.5 pg/mL developed this complication.

A mini-invasive approach is feasible in patients with primary hyperparathyroidism and discordant or negative localisation studies.

Preoperative localisation of pathological glands in patients with primary hyperparathyroidism (PHP) is the mainstay for mini-invasive parathyroidectomy. Nevertheless, a not negligible number of patients presents discordant or negative neck ultrasound (US) and 99mTc-Sestamibi (MIBI) scan. The aim of this study was to assess if a mini-invasive approach is feasible in this kind of patients. In this retrospective study were included patients that underwent parathyroidectomy for PHP. Patients were divided into two groups according to concordance of US and MIBI scan results. 242 patients were included: 183 had concordant preoperative studies, and 59 had discordant or negative studies. A mini-invasive approach was possible in 42 (72.9%) patients with unclear preoperative studies, whereas 12 (20.3%) additional patients required conversion to BNE. The incidence of persistent PHP was higher in patients with unclear preoperative studies (8.5% vs 2.7%), but this difference did not reach a statistical significance (p = 0.121). In patients with unclear preoperative studies, a negative result of intraoperative PTH allowed to avoid a persistent disease in 12 patients, while in 3 cases led to an unnecessary additional exploration. In patients with discordant preoperative studies a mini-invasive approach is feasible; in this setting, the use of intraoperative PTH is mandatory to reduce the incidence of persistent PHP.

Risk factors of permanent hypoparathyroidism after total thyroidectomy Retrospective analysis of 285 consecutive patients.

AIM: Permanent hypoparathyroidism is the most common long-term complication after total thyroidectomy. The aim of the present study was to investigate the risk factors of this complication. MATERIAL AND METHODS: Patients undergoing thyroidectomy in our Unit between January 2017 and February 2018 were retrospectively analysed. They were divided into 2 groups: those with normal parathyroid function in the long term were included in Group A, those who developed permanent hypoparathyroidism in Group B. RESULTS: Two hundred and eighty-five patients were included in this study: 271 in Group A and 14 in Group B. No statistically significant difference was found in terms of sex, age, extent of surgery, rate of retrosternal goiter, postoperative stay and histopathological findings between the 2 groups. On the contrary, mean operative time, rate of patients with PTH values < 6.3 pg/mL on postoperative day 1 and mean thyroid weight were significantly greater in Group B than in Group A (P = 0.049, P < 0.001, P = 0.014; respectively). CONCLUSIONS: Long operative times, PTH levels < 6.3 pg/mL on postoperative day 1 and high thyroid weight have proved to be strong risk factors of permanent hypoparathyroidism after total thyroidectomy. Thus, in these cases a careful follow-up is highly recommended. KEY WORDS: Permanent hypoparathyroidism, Risk factors, Total thyroidectomy.

The role of Rapid Intraoperative Parathyroid Hormone (ioPTH) assay in determining outcome of parathyroidectomy in primary hyperparathyroidism: A systematic review and meta-analysis.

BACKGROUND: Primary hyperparathyroidism (PHPT) is a common endocrine disorder. In the last few decades, the introduction of Rapid Intraoperative Parathyroid Hormone (ioPTH) monitoring has allowed to ensurance of the excision of all hyperfunctioning parathyroid tissues, reducing the risks of persistent and recurrent PHPT. However, the use of ioPTH is still debated among endocrine surgeons. MATERIAL AND METHODS: The objective of this systematic review and meta-analysis was to assess if ioPTH monitoring is able to reduce the incidence of persistent or recurrent PHPT. A systematic literature search was performed using PubMed, Scopus, ISI-Web of Science and Cochrane Library Database. Prospective and retrospective studies addressing the efficacy of ioPTH monitoring were included in the systematic review and meta-analysis. The random-effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated. RESULTS: A total of 28 studies with 13,323 patients were included in the quantitative analysis. The incidence of operative failure was 3.2% in the case group and 5.8% in the control group. After excluding three outlier studies, the quantitative analysis revealed that ioPTH reduced significantly the incidence of postoperative persistent or recurrent PHPT. (Risk Difference = -0.02; CI = -0.03, -0.01; p < 0.001). There was no evidence of heterogeneity among the studies (Q = 19.92, p = 0.70; I2 = 0%). The analysis of several continuous moderators revealed that the effectiveness of ioPTH was larger in studies with lower preoperative serum calcium values and higher incidences of multiple gland disease. CONCLUSION: ioPTH monitoring is effective in reducing the incidence of persistent and recurrent PHPT. Its routine use should be suggested in the next guidelines regarding management of PHPT.

Is extensive surgery really necessary in patients with parathyroid carcinoma? Single-centre experience and a brief review of the literature.

AIM: Parathyroid carcinoma (PC) represents a rare cause of primary hyperparathyroidism (PHPT). In this paper, among patients who underwent surgery for PHPT, we compared those with benign parathyroid disease with those affected by PC in terms of demographic and preoperative biochemical features. Moreover, we singularly described all 10 cases of PC treated at our Institution (including a case that occurred in a patient with tertiary hyperparathyroidism) and a brief review of the literature. MATERIAL AND METHODS: Patients undergoing surgery for PHPT in our Unit between 2003 and 2018 were retrospectively analysed. They were divided into two groups: Group A (benign parathyroid disease), Group B (PC). The case of PC that occurred in the patient with tertiary hyperparathyroidism was not included into the two groups. RESULTS: Three hundred and eight patients were included: 299 in Group A and 9 in Group B. The mean preoperative serum PTH value and mean preoperative serum calcium level were significantly higher in Group B than in Group A (P = 0.018, P = 0.027; respectively). Including the case of PC that occurred in the patient with tertiary hyperparathyroidism, 10 patients with PC were treated at our Institution. Among these, 3 underwent a re-exploration. Disease recurrence occurred in 1 (10%) patient, who developed a local recurrence and distant metastases. CONCLUSIONS: In the presence of PHPT characterized by particularly high preoperative levels of serum PTH and calcium this malignancy should be suspected. On the basis of our experience, we believe that extensive surgery is not always necessary. KEY WORDS: Hyperparathyroidism, Parathyroid carcinoma, Parathyroid surgery.