Role of Locoregional Therapies in the Treatment of Thyroid Pathology: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel.

The role of locoregional therapy in the management of thyroid pathology is rapidly evolving. The Society of Interventional Radiology (SIR) Foundation commissioned an international research consensus panel consisting of physicians from multiple disciplines with expertise in the management of benign and malignant thyroid disease. The panel focused on identifying gaps in the current body of literature to establish research priorities that have the potential to shape the landscape of minimally invasive thyroid interventions. The topics discussed were centered on the emerging role of ablation for malignant thyroid tumors and the treatment of large functioning nodules with embolization and ablation. Specifically, the panel prioritized identifying nodule characteristics, including size and location, that are associated with ideal outcomes following thermal ablation for papillary thyroid microcarcinoma through the development of an international registry or a prospective, multi-institutional trial. The panel also prioritized evaluating the role of locoregional therapy in Stage T1b papillary thyroid cancer through a sequence of 2 studies: (a) a Phase I study of ablation followed by immediate resection of Stage T1b papillary thyroid cancer, which may lead to (b) a Phase II prospective, multi-institutional study of ablation followed by biopsy for Stage T1b papillary thyroid cancer. Lastly, the panel prioritized investigating the treatment of large, functioning thyroid nodules >20 mL in volume through a randomized clinical trial or prospective registry comparing embolization alone with embolization followed by ablation.

The Influence of Impedance on the Efficacy of Radiofrequency Ablation for Benign Thyroid Nodules.

OBJECTIVE: Radiofrequency ablation (RFA) uses the heat generated by a high-frequency alternating electric current, and according to Ohm's and Joule's law, the delivered current is inversely proportional to the circuit impedance. The primary objective of this study was to investigate whether tissue impedance during radiofrequency ablation (RFA) for benign thyroid nodules is related to the degree of volume reduction. METHODS: This observational study included consecutive patients treated with RFA for benign thyroid nodules from February 2020 to August 2023. Technical effectiveness was defined as a volume reduction percentage (VRP) >75% at 6 months after the treatment. Multivariate logistic regression analyses were performed to identify the potential role of clinical factors and changes in tissue impedance on technique effectiveness. RESULTS: Totally 72 patients were included with 73 benign thyroid nodules. Maximal impedance peaks reached <18 times, and mean procedural impedance ≤300 Ω were significantly associated with a volume decrease of >75% at bivariate analysis. These cutoff points were exploratory, as no existing literature suggests these variables are related to the degree of volume reduction. After adjusting for age, volume, and composition, significant associations were found for mean electrical impedance in the multivariate analysis (OR = 4.86 [confidence interval [CI] 1.29-18.26], p = 0.019). The energy adjusted by volume (delivered energy) was not associated with a VRP >75% (p = 0.7746). CONCLUSIONS: This study suggests that a mean procedural impedance

Bacterial Colonization on Endoscopic Materials and Surgical Field Without Infections After Transoral Endoscopic Thyroidectomy.

INTRODUCTION: Our aim was to determine whether bacteria contamination occurred within the surgical field or on endoscopic equipment during surgery using the transoral endoscopic thyroidectomy vestibular approach (TOETVA). MATERIALS AND METHODS: Participants were recruited from patients planned for TOETVA between May 2017 and December 2019. Bacterial samples were taken before and at the conclusion of the TOETVA procedure. The preoperative and postoperative samples were taken from the endoscopic materials and inferior oral vestibulum using a sterile flocked swab. RESULTS: The study resulted in 480 samples (80 TOETVAs). No vestibular, port site, or neck infections occurred in any of the patients. Three (3.7%) out of 80 patients developed postoperative fever. Our results show different microbial communities during TOETVA. The most prevalent species detected were S treptococcus species. Multivariate logistic regression analyses revealed that the degree of contamination depended on the sampling site (inferior vestibulum > equipment) ( P =0.03). In addition, the abundance of bacteria was affected by operative time ( P =0.013). There were no significant differences observed in isolation frequencies of bacteria in malignancy ( P =0.34). CONCLUSIONS: TOETVA surgery is categorized as a "clean-contaminated" operation. A swab identified the common colonizers of oral microbiota on the endoscopic equipment and within the surgical field.

Long-term Quality of Life After Thyroidectomy: Transoral Endoscopic Thyroidectomy Vestibular Approach Versus Transcervical Approach.

OBJECTIVE: To compare long-term health-related quality of life (HRQOL) after Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) and transcervical approach (TCA) thyroidectomy. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral center. METHODS: A web-based survey was distributed to patients at our institution who met the criteria for TOETVA and underwent thyroidectomy by TOETVA or TCA between August 2017 and October 2021. All survey participants were at least 6 months postsurgery. Minors, non-English speakers, and patients who received concomitant neck dissection or reoperative thyroidectomy were excluded from the study. The survey assessed quality of life through 4 standardized instruments: the Dermatology Life Quality Index (DLQI), the Eating Assessment Tool (EAT-10), the Voice Handicap Index (VHI-10), and the Short Form Health Survey (SF-36). RESULTS: A total of 108 TOETVA and 129 TCA patients were included in the study. The median age of respondents was 44 (36, 54; 25th, 75th percentile) years and median time from surgery to survey was 35 (22, 45; 25th, 75th percentile) months. TOETVA group DLQI (0.63 vs 0.99; P = .17), VHI-10 (1.94 vs 1.67; P = .35), EAT-10 (2.14 vs 2.32; P = .29), SF-36 physical component (52.25 vs 51.00; P = .25), and SF-36 mental component (47.74 vs 47.29; P = .87) scores were all similar to those of the TCA group. Scrutinizing specific DLQI questions, individuals in the TOETVA group were less self-conscious of their skin as compared to the TCA group (Q2; 0.08 vs 0.26, P = .03). CONCLUSION: Long-term HRQOL after TOETVA is similar to TCA, with significantly lower skin-related self-consciousness.

A clinical practice review of percutaneous ethanol injection for thyroid nodules: state of the art for benign, cystic lesions.

Percutaneous ethanol injection (PEI) is a widely used treatment option for cystic and predominantly cystic thyroid nodules. It has several advantages over other treatment modalities. Compared to surgery, PEI is less painful, can be performed in the outpatient setting, and carries less risk of transient or permanent side effects. Compared to other minimally invasive techniques such as radiofrequency ablation (RFA), PEI is less expensive and does not require specialized equipment. PEI performs well in the context of cystic nodules. PEI does not perform as well as other techniques in solid nodules, so its use as a primary treatment is limited to cystic and predominantly cystic thyroid nodules. However, PEI is also being explored as an adjunct treatment to improve ablation of solid nodules with other techniques. Here, we provide a clinical review discussing the genesis, mechanism of action, and patient selection with respect to ethanol ablation, as well as the procedure itself. Predictors of operative success, failure, and common adverse events are also summarized. Altogether, PEI allows impressive volume reduction rates with minimal complications. Several recent studies have also evaluated the long-term impact of PEI up to 10 years after treatment and revealed maintenance of robust treatment efficacy with no undesirable long-term sequelae. Thus, PEI remains the treatment of choice for benign but symptomatic cystic and predominantly cystic thyroid nodules.

Radiofrequency ablation of benign thyroid nodules: A prospective, multi-institutional North American experience.

BACKGROUND: Radiofrequency ablation for benign thyroid nodules aims to achieve a volume reduction rate of ≥50%. However, factors that predict treatment success have not been defined in a large-scale study. METHODS: A prospective cohort study of biopsy-proven benign thyroid nodules treated with radiofrequency ablation at 3 institutions was performed. Patient demographics, nodule sonographic features, procedural data, and nodule volume reduction were evaluated. Binary logistic regression analysis was performed to identify features associated with treatment response. RESULTS: A total of 620 nodules were analyzed. The pooled median volume reduction rate at 12 months was 70.9% (interquartile range 52.9-86.6). At 1 year follow-up, 78.4% of nodules reached treatment success with a volume reduction rate ≥50%. The overall complication rate was 3.2% and included temporary voice changes (n = 14), vasovagal episodes (n = 5), nodule rupture (n = 3), and lightheadedness (n = 2). No permanent voice changes occurred. Four patients developed postprocedural hypothyroidism. Large baseline nodule volume (>20 mL) was associated with a lower rate of successful volume reduction (odds ratio 0.60 [0.37-0.976]). Large nodules achieved treatment success by 12-month follow-up at a rate of 64.5%, compared with 81.4% for small nodules and 87.2% for medium nodules. CONCLUSION: To our knowledge, this is the largest North American cohort of patients with benign thyroid nodules treated with radiofrequency ablation. Overall, radiofrequency ablation was an effective treatment option with a low risk of procedural complications. Large volume nodules (>20 mL) may be associated with a lower rate of successful reduction with radiofrequency ablation treatment.

Parathyroid gland detection using an intraoperative autofluorescence handheld imager - early feasibility study.

Introduction: Parathyroid glands may be compromised during thyroid surgery which can lead to hypoparathyroidism and hypocalcemia. Identifying the parathyroid glands relies on the surgeon's experience and the only way to confirm their presence was through tissue biopsy. Near infrared autofluorescence technology offers an opportunity for real-time, non-invasive identification of the parathyroid glands. Methods: We used a new research prototype (hANDY-I) developed by Optosurgical, LLC. It offers coaxial excitation light and a dual-Red Green Blue/Near Infrared sensor that guides anatomical landmarks and can aid in identification of parathyroid glands by showing a combined autofluorescence and colored image simultaneously. Results: We tested the imager during 23 thyroid surgery cases, where initial clinical feasibility data showed that out of 75 parathyroid glands inspected, 71 showed strong autofluorescence signal and were correctly identified (95% accuracy) by the imager. Conclusions: The hANDY-I prototype demonstrated promising results in this feasibility study by aiding in real-time visualization of the parathyroid glands. However, further testing by conducting randomized clinical trials with a bigger sample size is required to study the effect on levels of hypoparathyroidism and hypocalcemia.

Locoregional strategies to decrease postoperative pain and neck discomfort after open thyroidectomy: A scoping review.

Adequate pain control enhances patients' quality of life and allows a quick return to normal activities. Current pain management practices may contribute to the crisis of opioid addiction. We summarize the evidence that evaluates locoregional interventions to decrease pain and neck discomfort after thyroidectomy. We designed a scoping review. The search strategy was made in the Pubmed/MEDLINE and EMBASE database. We included only systematic reviews and RCTs that compared two or more strategies. Forty-nine publications including 5045 patients fulfilled criteria. Sore throat frequency is higher for endotracheal intubation and topical administration of anesthetic before intubation decreases this. Pre-incisional infiltration of the surgical wound decreases postoperative pain. Bilateral superficial plexus nerve block decreases analgesic requirements during and after thyroidectomy. Wound massage and neck exercises decrease postoperative discomfort. Locoregional interventions significantly impact postoperative pain and may reduce opioid use and improve patient outcomes.

Neck Surgery for Non-Well Differentiated Thyroid Malignancies: Variations in Strategy According to Histopathology.

Lymph node metastases in non-well differentiated thyroid cancer (non-WDTC) are common, both in the central compartment (levels VI and VII) and in the lateral neck (Levels II to V). Nodal metastases negatively affect prognosis and should be treated to maximize locoregional control while minimizing morbidity. In non-WDTC, the rate of nodal involvement is variable and depends on the histology of the tumor. For medullary thyroid carcinomas, poorly differentiated thyroid carcinomas, and anaplastic thyroid carcinomas, the high frequency of lymph node metastases makes central compartment dissection generally necessary. In mucoepidermoid carcinomas, malignant peripheral nerve sheath tumors, sarcomas, and malignant thyroid teratomas or thyroblastomas, central compartment dissection is less often necessary, as clinical lymphnode involvement is less common. We aim to summarize the medical literature and the opinions of several experts from different parts of the world on the current philosophy for managing the neck in less common types of thyroid cancer.

Review: Improving quality of life in patients with differentiated thyroid cancer.

Well differentiated thyroid cancer is a common malignancy diagnosed in young patients. The prognosis tends to be excellent, so years of survivorship is expected with low risk disease. When making treatment decisions, physicians should consider long-term quality of life outcomes when guiding patients. The implications for treating indolent, slow growing tumors are immense and warrant careful consideration for the functioning years ahead. Surgery is the standard of care for most patients, however for a subset of patients, active surveillance is appropriate. For those wishing to treat their cancer in a more active way, novel remote access approaches have emerged to avoid a cervical incision. In the era of "doing less", options have further expanded to include minimally invasive approaches, such as radiofrequency ablation that avoids an incision, time off work, a general anesthetic, and the possibility of post-treatment hypothyroidism. In this narrative review, we examine the health related quality of life effects that surgery has on patients with thyroid cancer, including some of the newer innovations that have been developed to address patient concerns. We also review the impact that less aggressive treatment has on patient care and overall wellbeing in terms of active surveillance, reduced doses of radioactive iodine (RAI) treatment, or minimally invasive techniques such as radiofrequency ablation (RFA) for low risk thyroid disease.

Management of Recurrent Well-Differentiated Thyroid Carcinoma in the Neck: A Comprehensive Review.

Surgery has been historically the preferred primary treatment for patients with well-differentiated thyroid carcinoma and for selected locoregional recurrences. Adjuvant therapy with radioactive iodine is typically recommended for patients with an intermediate to high risk of recurrence. Despite these treatments, locally advanced disease and locoregional relapses are not infrequent. These patients have a prolonged overall survival that may result in long periods of active disease and the possibility of requiring subsequent treatments. Recently, many new options have emerged as salvage therapies. This review offers a comprehensive discussion and considerations regarding surgery, active surveillance, radioactive iodine therapy, ultrasonography-guided percutaneous ablation, external beam radiotherapy, and systemic therapy for well-differentiated thyroid cancer based on relevant publications and current reference guidelines. We feel that the surgical member of the thyroid cancer management team is empowered by being aware and facile with all management options.

3D Transoral Endoscopic Thyroid.

Transoral endoscopic thyroidectomy with vestibular approach (TOETVA) is a feasible new surgical procedure that does not require visible incisions. We describe our experience with three-dimensional (3D) TOETVA. We recruited 98 patients who were willing to undergo 3D TOETVA. Inclusion criteria were: (a) patients with a neck ultrasound (US) with an estimated thyroid diameter of 10cm or less; (b) estimated US gland volume ≤45ml; (c) nodule size ≤50mm; (d) benign tumor, such as thyroid cyst, goiter with one nodule, or goiter with multiple nodules; (e) follicular neoplasia; and (f) papillary microcarcinoma without evidence of metastases. The procedure is performed using a three-port technique at the oral vestibule, a 10mm port for the 30° endoscope, and two additional 5mm ports for dissecting and coagulation instruments. The CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule to the sternal notch and laterally to the sternocleidomastoid muscle. Thyroidectomy is performed entirely 3D endoscopically with conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. Ninety-eight 3D TOETVA procedures were successfully performed without any conversions. The mean operative time was 87.6 minutes (59-118 minutes) for lobectomy and 107.6 minutes (99-135 minutes) for bilateral surgery. We observed one case of transient postoperative hypocalcemia. Paralysis of the recurrent laryngeal nerve did not occur. The cosmetic outcome was excellent in all patients. This is the first case series of 3D TOETVA.

A multicenter evaluation of near-infrared autofluorescence imaging of parathyroid glands in thyroid and parathyroid surgery.

BACKGROUND: The usefulness of incorporating near-infrared autofluorescence into the surgical workflow of endocrine surgeons is unclear. Our aim was to develop a prospective registry and gather expert opinion on appropriate use of this technology. METHODS: This was a prospective multicenter collaborative study of patients undergoing thyroidectomy and parathyroidectomy at 7 academic centers. A questionnaire was disseminated among 24 participating surgeons. RESULTS: Overall, 827 thyroidectomy and parathyroidectomy procedures were entered into registry: 42% of surgeons found near-infrared autofluorescence useful in identifying parathyroid glands before they became apparent; 67% correlated near-infrared autofluorescence pattern to normal and abnormal glands; 38% of surgeons used near-infrared autofluorescence, rather than frozen section, to confirm parathyroid tissue; and 87% and 78% of surgeons reported near-infrared autofluorescence did not improve the success rate after parathyroidectomy or the ability to find ectopic glands, respectively. During thyroidectomy, 66% of surgeons routinely used near-infrared autofluorescence to rule out inadvertent parathyroidectomy. However, only 36% and 45% felt near-infrared autofluorescence decreased inadvertent parathyroidectomy rates and improved ability to preserve parathyroid glands during central neck dissections, respectively. CONCLUSION: This survey study identified areas of greatest potential use for near-infrared autofluorescence, which can form the basis of future objective trials to document the usefulness of this technology.

Surgical treatment of thyroid cancer: Established and novel approaches.

Thyroid surgery is one of the most common head and neck procedures. The thyroid can be accessed through an anterior cervical incision, or by remote access techniques such as the transoral endoscopic thyroidectomy vestibular approach (TOETVA) which is favored for its ease, safety and direct plane to the thyroid gland. Other novel approaches for targeting small-localized well-differentiated thyroid cancer are by thermal ablation, namely ultrasound guided radiofrequency ablation. These innovative techniques for minimizing a cutaneous scar or for targeting small cancers directly without removal of the gland have developed alongside our realization that low risk well-differentiated thyroid cancer tends to be slow growing and indolent. Up to date, the most robust data supports offering these therapies primarily to patients who would be eligible for active surveillance protocols. In this paper, we review the traditional surgical approaches for removing well-differentiated thyroid cancer, as well as innovative remote access techniques (namely TOETVA), and minimally invasive thermal ablation (namely RFA).

Cost comparison between open thyroid lobectomy and radiofrequency ablation for management of thyroid nodules.

BACKGROUND: There is an increasing array of treatment options for addressing clinically significant thyroid nodules, including radiofrequency ablation (RFA). While effective, the cost compared to alternative approaches has not been well elucidated. METHODS: This study involved a retrospective chart review, focusing on variable direct cost (VDC) of each procedure, from April 2016 to January 2020. We analyzed costs for 53 open lobectomies and 16 RFA procedures. RESULTS: Cost effectiveness depended on the simulated cost of the RFA probe. In comparison to open lobectomy, the VDC to perform RFA was $597 (19%) cheaper when the simulated probe cost was $1500 and $403 (13%) more expensive for a probe cost of $2500. Statistical significance was achieved for both these differences. CONCLUSIONS: If cost per RFA probe can be less than $2100-the break-even dollar amount between open lobectomy and RFA-there would be considerable cost savings for treating thyroid nodules.

Radiofrequency ablation as a novel modality in the USA for treating toxic thyroid nodules: case series and literature review.

Background: Radiofrequency ablation (RFA) is widely accepted as a treatment for non-functioning benign thyroid nodules, mainly to reduce compressive symptoms. In addition to potential compressive symptoms, autonomously functioning thyroid nodules (AFTNs) can cause palpitations, weight loss, diarrhea, increased appetite, flushing, irritability, tiredness, poor sleep, and long-term cardiovascular and musculoskeletal consequences. Currently, there are no United States based RFA practice guidelines for the treatment of AFTNs. However, several reports from Asia and Europe have described the resolution of hyperthyroidism secondary to AFTNs with RFA. Case Description: Three patients with toxic thyroid nodules presented with symptomatic hyperthyroidism, suppressed thyroid-stimulating hormone (TSH), and increased uptake on nuclear medicine thyroid scan. These patients were treated with RFA. At 3 months following ablation, TSH normalized to 2.09, 1.91, and 1.34 mIU/mL respectively. However, temporary hypothyroidism was encountered at 1 month following ablation. All patients discontinued their antithyroid medications following ablation. Nodules exhibited significant volume reductions of 38%, 32%, and 54% from the baseline at 1-month follow-up. Conclusions: RFA potentiates as a safe and effective treatment of toxic thyroid nodules. Though it carries a risk of temporary hypothyroidism following ablation, long-term consequences appear to be minimal. Future study with larger sample size and longer follow-up are encouraged to identify factors predicting response.

Effectiveness of core needle biopsy in the diagnosis of thyroid lymphoma and anaplastic thyroid carcinoma: A systematic review and meta-analysis.

Background: Both anaplastic thyroid carcinoma (ATC) and thyroid lymphoma (TL) clinically present as rapidly enlarging neck masses. Unfortunately, in this situation, like in any other thyroid swelling, a routine fine-needle aspiration (FNA) cytology is the first and only diagnostic test performed at the initial contact in the average thyroid practice. FNA, however, has a low sensitivity in diagnosing ATC and TL, and by the time the often "inconclusive" result is known, precious time has evolved, before going for core-needle biopsy (CNB) or incisional biopsy (IB) as the natural next diagnostic steps. Objectives: To determine the diagnostic value of CNB in the clinical setting of a rapidly enlarging thyroid mass, via a systematic review and meta-analysis of the available data on CNB reliability in the differential diagnosis of ATC and TL. Methods: A PubMed, Embase and Web of Science database search was performed on June 23th 2021. Population of interest comprised patients who underwent CNB for clinical or ultrasonographical suspicion of ATC or TL, patients with a final diagnosis of ATC or TL after CNB, or after IB following CNB. Results: From a total of 17 studies, 166 patients were included. One hundred and thirty-six were diagnosed as TL and 14 as ATC following CNB. CNB, with a sensitivity and positive predictive value of 94,3% and 100% for TL and 80,1% and 100% for ATC respectively, proved to be superior to FNA (reported sensitivity for TL of 48% and for ATC of 61%). Furthermore, the need for additional diagnostic surgery after CNB was only 6.2% for TL and 17.6% for ATC. Conclusions: Immediately performing CNB for a suspected diagnosis of ATC and TL in a rapidly enlarging thyroid mass is more appropriate and straightforward than a stepped diagnostic pathway using FNA first and awaiting the result before doing CNB.

Evaluating new treatments for anaplastic thyroid cancer.

INTRODUCTION: Anaplastic thyroid cancer (ATC) is one of the most lethal diseases known to humans with a median survival of 5 months. The American Thyroid Association (ATA) recently published guidelines for the treatment of this dreadful thyroid malignancy. AREAS COVERED: This review presents the current therapeutic landscape of this challenging disease. We also present the results from trials published over the last five years and summarize currently active clinical trials. EXPERT OPINION: Recent attempts to improve the prognosis of these tumors are moving toward personalized medicine, basing the treatment decision on the specific genetic profile of the individual tumor. The positive results of dabrafenib and trametinib for ATC harboring the BRAF V600E mutation have provided a useful treatment option. For the other genetic profiles, different drugs are available and can be used to individualize the treatment, likely using drug combinations. Combinations of drugs act on different molecular pathways and achieve inhibition at separate areas. With new targeted therapies, average survival has improved considerably and death from local disease progression or airway compromise is less likely with improvement in quality of life. Unfortunately, the results remain poor in terms of survival.

Efficacy and Safety of Radiofrequency Ablation of Thyroid Nodules: A Multi-institutional Prospective Cohort Study.

BACKGROUND: Radiofrequency ablation (RFA) has been recently adopted into the practice of thyroidology in the United States, although its use as an alternative to traditional thyroid surgery in Asia and Europe came near the turn of the 21st century. In the United States, only a few studies with small sample sizes have been published to date. We examined outcomes of benign thyroid nodules treated with RFA from 2 North American institutions. METHODS: We performed a prospective, multi-institutional cohort study of thyroid nodules treated with RFA between July 2019 and January 2022. Demographics, sonographic characteristics of thyroid nodules, thyroid function profiles, procedural details, complications, and nodule volume measurements at 1, 3, 6, and 12 months follow-up were evaluated. Adjusted multivariate logistic regression analysis was performed to identify sonographic features associated with treatment failure. RESULTS: A total of 233 nodules were included. The median and interquartile range of volume reduction rate (VRR) at 1, 3, 6, and 12 months were 54% [interquartile range (IQR): 36%-73%], 58% (IQR: 37%-80%), 73% (IQR: 51%-90%), and 76% (IQR: 52%-90%), respectively ( P <0.001). Four patients presented with toxic adenomas. All patients were confirmed euthyroid at 3-month postprocedure follow-up. Two patients developed temporary hoarseness of voice, but no hematoma or nodular rupture occurred postprocedure. Elastography was significantly associated with VRR. Compared with soft nodules, stiff nodules were more likely to have a lower VRR (odds ratio: 11.64, 95% confidence interval: 3.81-35.53, P <0.05), and mixed elasticity was also more likely to have a lower VRR (odds ratio: 4.9; 95% confidence interval: 1.62-14.85, P <0.05). CONCLUSIONS: This is the largest multi-institutional North American study examining thyroid nodule treatment response to RFA. RFA is a safe and effective treatment option that allows preservation of thyroid function with minimal risk of procedural complications.

Peri-Operative Pain and Opioid Use in Opioid-Naïve Patients Following Inpatient Head and Neck Surgery.

Pain management is an important consideration for Head and Neck Cancer (HNC) patients as they are at an increased risk of developing chronic opioid use, which can negatively impact both quality of life and survival outcomes. This retrospective cohort study aimed to evaluate pain, opioid use and opioid prescriptions following HNC surgery. Participants included patients undergoing resection of a head and neck tumor from 2019-2020 at a single academic center with a length of admission (LOA) of at least 24 h. Exclusion criteria were a history of chronic pain, substance-use disorder, inability to tolerate multimodal analgesia or a significant post-operative complication. Subjects were compared by primary surgical site: Neck (neck dissection, thyroidectomy or parotidectomy), Mucosal (resection of tumor of upper aerodigestive tract, excluding oropharynx), Oropharyngeal (OP) and Free flap (FF). Average daily pain and total daily opioid consumption (as morphine milligram equivalents, MME) and quantity of opioids prescribed at discharge were compared. A total of 216 patients met criteria. Pain severity and daily opioid consumption were comparable across groups on post-operative day 1, but both metrics were significantly greater in the OP group on the day prior to discharge (DpDC) (5.6 (1.9-8.6), p < 0.05; 49 ± 44 MME/day, p < 0.01). The quantity of opioids prescribed at discharge was associated with opioid consumption on the DpDC only in the Mucosal and FF groups, which had longer LOA (6-7 days) than the Neck and OP groups (1 day, p < 0.001). Overall, 65% of patients required at least one dose of an opioid on the DpDC, yet 76% of patients received a prescription for an opioid medication at discharge. A longer LOA (aOR = 0.82, 95% CI: 0.63-0.98) and higher Charlson Comorbidity Index (aOR = 0.08, 95% CI: 0.01-0.48) were negatively associated with receiving an opioid prescription at the time of discharge despite no opioid use on the DpDC, respectively. HNC patients, particularly those with shorter LOA, may be prescribed opioids in excess of their post-operative needs, highlighting the need the for improved pain management algorithms in this patient population. Future work aims to use prospective surveys to better define post-operative and outpatient pain and opioid requirements following HNC surgery.