Subtotal Versus Total Parathyroidectomy for the Management of Tertiary Hyperparathyroidism: A Systematic Literature Review and Meta-Analysis of Optimal Surgical Modality.

Background: Surgery is the definitive treatment option for tertiary hyperparathyroidism (THPT), however, the optimal surgical approach remains unclear. We aimed to compare total parathyroidectomy (PTX) with auto-transplantation vs subtotal PTX for THPT through a systematic review and meta-analysis.Methods: PubMed, Embase, and Web of Science were searched for studies comparing outcomes of total vs subtotal PTX for THPT. A total of 28 studies (n = 1000 patients) met the inclusion criteria.Results: The mean age was 46.5 years and 53% were female. The proportion of females (59% vs 49%) was higher in the total PTX with auto-transplantation cohort (P = .008). Both procedures had similar preoperative calcium and PTH levels. Postoperative and 6-month calcium and PTH were also comparable between groups, except transiently higher post-operative PTH in the total PTX with auto-transplantation cohort (P = .03). Hypercalcemia cure rates were 98%-100% with no difference between surgical techniques (P = .67). Safety profiles were comparable and low.Conclusions: Total PTX with auto-transplantation and subtotal PTX yield similar efficacy and safety for THPT, with no significant differences in cure rates, recurrence, complications, or biochemical control.

Evaluating the Efficacy and Safety of Robotic Versus Conventional Completion Thyroidectomy: A 10-year Experience.

BACKGROUND: Robotic thyroidectomy is gaining popularity, yet its role in completion thyroidectomy remains unclear. We aimed to compare robotic vs conventional completion thyroidectomy for thyroid nodules. METHODS: This retrospective study analyzed patients undergoing completion thyroidectomy from 2010-2020, either by conventional open technique (n = 87) or a robotic remote-access approach (n = 44). Outcomes were compared between groups. RESULTS: A total of 131 patients were included. The robotic cohort was younger (45.3 ± 14.0 vs 55.5 ± 14.5 years, P < 0.001) with a lower BMI (25.9 ± 5.5 vs 33.7 ± 7.8 kg/m2, P < 0.001). Operative time was longer for robotic procedures (139 min vs 99 min, P < 0.001). Hospital stay was shorter after robotic surgery, with 25% discharged the same day as compared to 5.7% in the open thyroidectomy cohort (P = 0.006). Overall rates of complication were comparable (P = 0.65). Transient recurrent laryngeal nerve palsy occurred in 4.6% of patients, which was similar between both cohorts (P = 0.66). CONCLUSION: Robotic completion thyroidectomy appears safe and effective, achieving shorter hospitalization than conventional open approaches despite longer operative times. Appropriate patient selection and surgical technique optimization are key. Larger prospective studies should investigate costs and long-term patient-reported outcomes.

Initial versus Staged Thyroidectomy for Differentiated Thyroid Cancer: A Retrospective Multi-Dimensional Cohort Analysis of Effectiveness and Safety.

The optimal surgical approach for differentiated thyroid cancer remains controversial, with debate regarding the comparative risks of upfront total thyroidectomy versus staged completion thyroidectomy following the initial lobectomy. This study aimed to assess the complication rates associated with these two strategies and identify the optimal timing for completion thyroidectomy using a multi-dimensional analysis of four cohorts: an institutional series (n = 148), the National Surgical Quality Improvement Program (NSQIP) database (n = 39,992), the TriNetX repository (n > 30,000), and a pooled literature review (10 studies, n = 6015). Institutional data revealed higher overall complication rates with total thyroidectomy (18.3%) compared to completion thyroidectomy (6.8%), primarily due to increased temporary hypocalcemia (10% vs. 0%, p = 0.004). The NSQIP analysis demonstrated that total thyroidectomy was associated with a 72% increased risk of transient hypocalcemia (p < 0.001) and a 25% increased risk of permanent hypocalcemia (p < 0.001). TriNetX data confirmed these findings and identified obesity and concurrent neck dissection as risk factors for complications. A meta-analysis showed that total thyroidectomy increased the rates of transient (RR = 1.63) and permanent (RR = 1.23) hypocalcemia (p < 0.001). Institutional and TriNetX data suggested that performing completion thyroidectomy between 1 and 6 months after the initial lobectomy minimized permanent complication rates compared to delays beyond 6 months. In conclusion, for differentiated thyroid cancer, total thyroidectomy is associated with higher risks of transient and permanent hypocalcemia compared to staged completion thyroidectomy. However, performing completion thyroidectomy within 1-6 months of the initial lobectomy may mitigate the risk of permanent complications. These findings can inform personalized surgical decision-making for patients with differentiated thyroid cancer.

Clinical outcomes and tumor microenvironment response to radiofrequency ablation therapy: a systematic review and meta-analysis.

Background: Radiofrequency ablation (RFA) utilizes minimally invasive high-energy current to precisely ablate tumor cells. It has been utilized in many cancer types including thyroid, lung, and liver cancer. It has been shown to provide adequate ablative margins with minimal complications; however, incomplete RFA may lead to recurrence of tumor. The underlying cellular mechanism and behavior of ablated cancer tissue is poorly understood. Methods: A systematic review was performed, searching EMBASE, Web of Science, PubMed, and Scopus for studies published up to March 2022 and reported following PRISMA guidelines. Collection was performed by two groups of investigators to avoid risk of bias. The Cochrane Collaboration's tool was used for assessing risk of bias. We identified human, in vivo, and in vitro research studies utilizing RFA for tumor tissues. We required that the studies included at least one of the following: complications, recurrence, or survival, and took interest to studies identifying cellular signaling pathway patterns after RFA. Descriptive statistical analysis was performed in 'R' software including mean and confidence interval. Results: The most frequent cancers studied were liver and lung cancers accounting for 57.4% (N=995) and 15.4% (N=267), followed by esophageal (N=190) and breast cancer (N=134). The most common reported complications were bleeding (19%) and post-operative pain (14%). In our literature search, four independent studies showed upregulation and activation of the VEGF pathway following RFA, four showed upregulation and activation of the AKT pathway following RFA, three studies demonstrated involvement of matrix metalloproteinases, and four showed upregulation of c-Met protein following RFA. Conclusions: In our review and meta-analysis, we identify several proteins and pathways of interest of which are important in wound healing, angiogenesis, and cellular growth and survival. These proteins and pathways of interest may implicate areas of research towards RFA resistance and cancer recurrence.

Assessing Adequacy: A Meta-Analysis of Rapid Onsite Evaluation of Thyroid Nodules.

INTRODUCTION: Fine-needle aspiration (FNA) is the standard form of preoperative evaluation of thyroid nodule cytological status. A significant number FNAs are classified as inadequate for interpretation, requiring a repeat FNA which is potentially avoidable, costly, and delays treatment. To address these concerns and maximize first-time FNA adequacy, rapid onsite evaluation (ROSE) of FNA specimens was introduced. Our study aims to determine the impact of ROSE on FNA adequacy. METHODS: PubMed, Embase, and Web of Science were searched for primary articles assessing the adequacy of ROSE in thyroid nodules. RESULTS: A total of 17 studies were included for a total of 24,649 thyroid nodes. Thirteen thousand two hundred fifteen (53.6%) thyroid nodules were assessed utilizing ROSE and 11,434 (46.4%) were not. Pooled adequacy increased significantly from 76% without ROSE to 92% with rose (P = 0.001). Use of ROSE increased the odds of adequate FNA by 22% (risk ratio (RR) = 1.22, 95% confidence interval (CI) = 1.12-1.32). At institutions with less than 85% effective diagnostic adequacy without ROSE, the risk for diagnostic adequacy increased by 28% with ROSE implementation (RR = 1.28, 95% CI = 1.20-1.37). In contrast, in studies reported from institutions with an effective diagnostic rate greater than 85% without the use of ROSE, the diagnostic adequacy only increased by 5% with ROSE implementation (RR = 1.05, 95% CI = 1.03-1.06). CONCLUSIONS: The use of ROSE during first-time FNA of thyroid nodules can significantly improve adequacy, especially at institutions with baseline high inadequacy rates. Implementation of ROSE can reduce repeat FNAs and its associated consequences.

Microvascular surgery using surgical loupes versus operating microscope-A single head and neck reconstructive surgeon's experience.

BACKGROUND: This prospective randomized study evaluates surgical outcomes of head and neck free tissue transfer surgery performed by a single head and neck reconstructive surgeon comparing the use of surgical loupes and the operating microscope. METHODS: Cases using surgical loupes were performed under ×3.5 magnification, whereas cases using the microscope were done using the standard operating microscope. Patient demographics, comorbidities, operative details, surgical outcomes, and flap failure were assessed. RESULTS: Eighty-five free tissue transfer surgeries were included. Of these, 51.8% (n = 44) free tissue transfers were performed using loupe magnification and 48.2% (n = 41) were performed using the operating microscope. Total cases requiring intraoperative microvascular anastomosis revision was 12 (15.4%)-of these, 41.7% (n = 5) were originally performed with surgical loupes and 58.3% (n = 7) were with microscope (p = 0.24). CONCLUSION: The current study provides novel, prospective data regarding a single head and neck reconstructive surgeon's experience at a single academic institution. From this, surgical loupes or the operating microscope can be used to perform head and neck microvascular reconstruction with no significant difference in rates of free tissue transfer failure or perioperative complications or outcomes.

Completion thyroidectomy: A safe option for high-volume surgeons.

BACKGROUND: The risk of complication in patients undergoing completion thyroidectomy (cT) is mixed. Several studies report increased risk in comparison to total thyroidectomy (TT) and still others reporting a comparatively decreased risk. We compared the rates of complication in patients at our institution undergoing thyroid lobectomy (TL), (TT), and cT by a single high-volume surgeon. METHODS: We performed a single-institution retrospective cohort study. Patients undergoing TL, TT, or cT by a high-volume surgeon were included. Rates of complication were collected and compared between the three cohorts. RESULTS: A total of 310 patients were included. The overall rate of complication was 4.2%. The complication rates in the TL, TT, and cT cohorts were 1%, 7.1%, and 4.5%, respectively (p = 0.10). Transient hypocalcemia was slightly more common in the TT cohort (6.1%) as opposed to the TL (0%) or cT (0.9%) cohort (p = 0.01). The cohorts also had similar rates of recurrent laryngeal nerve signal loss leading to transient dysphonia (TL: 0% vs. TT: 1% vs. cT: 3.6%, p = 0.10). CONCLUSIONS: While rates of complication tended to predictably decrease as approaches became less extensive, there were no significant differences in complication rates among the three surgical approaches when performed by a high-volume surgeon. Considering the low rates of complication overall, patient counseling and preference should be emphasized to provide appropriate and tailored treatment plans.

From ablation to operation: Unraveling the surgical outcomes and complications of thyroidectomy after radiofrequency ablation.

BACKGROUND: Radiofrequency ablation is a minimally invasive treatment for thyroid nodules; however, concerns exist regarding its impact on subsequent thyroid surgery. We compared surgical outcomes and complications between patients undergoing thyroidectomy after radiofrequency ablation (post-radiofrequency ablation thyroidectomy group) and those without prior radiofrequency ablation (non-radiofrequency ablation thyroidectomy group). METHODS: We retrospectively analyzed thyroidectomy patients, comparing post-radiofrequency ablation thyroidectomy and non-radiofrequency ablation thyroidectomy groups, examining demographics, nodule characteristics, surgical techniques, and complications. RESULTS: The study included 96 patients (73 in the non-radiofrequency ablation thyroidectomy group and 23 in the post-radiofrequency ablation thyroidectomy group). The mean age was 53.3 ± 14.4 years, with 78.1% female patients and 36.5% African American patients. Median operative time was similar between the post-radiofrequency ablation thyroidectomy (110 minutes) and the non-radiofrequency ablation thyroidectomy (92 minutes) cohorts (P = .40). Complications were reported in 13 patients, without significant differences between groups (P = .54). No permanent complications, including nerve injury or hypoparathyroidism, were reported in either cohort. Prior radiofrequency ablation treatment did not increase the risk of complications (odds ratio = 3.48, 95% confidence interval = 0.70-17.43, P = .16). CONCLUSION: Our work found no differences in outcomes or safety in patients undergoing thyroidectomy with or without previous radiofrequency ablation treatment, potentiating the post-radiofrequency ablation thyroidectomy group as a safe management option. Accordingly, this may reassure both clinicians and patients of the safety of radiofrequency ablation in treating patients with thyroid nodules.

Bilateral nodule radiofrequency ablation in a single setting: First reported case series.

BACKGROUND: Radiofrequency ablation (RFA) is a minimally-invasive ablative technique with an impressive safety profile used to manage thyroid nodules. Current reports with RFA describe the treatment of a single nodule in a single-setting. We describe the first series of bilateral nodule RFA in a single-setting. METHODS: RFA was performed on patients with bilateral thyroid nodules in a single-setting. A cohort of randomly selected patients undergoing RFA for bilateral thyroid nodules in a separate setting was reported as a control cohort. RESULTS: A total of 12 patients were included in our series, included 6 patients in the single-setting ablation cohort. For patients with bilateral nodules treated by RFA in a separate setting, the mean volume reduction rate (VRR) at 6 months of 63.79% ± 18.86%. There were no reports of complications in the separate setting cohort. For patients with bilateral nodules treated by RFA in a single-setting, the mean VRR at 6 months was 64.% ± 18.97%. There were no reports of complications in the single-setting cohort. CONCLUSIONS: Our work describes a novel use of RFA, providing preliminary insight into its use for appropriately selected patients with bilateral thyroid nodules. Future studies with larger sample sizes are warranted to corroborate and expand on our findings.

Recommend with caution: A meta-analysis investigating papillary thyroid carcinoma tumor progression under active surveillance.

BACKGROUND: Papillary thyroid carcinoma (PTC) is an indolent disease with favorable outcomes. The non-surgical treatment approach known as active surveillance (AS) has been introduced as an alternative treatment instead of the traditional thyroidectomy. However, 10-15 % of PTC tend to progress. We sought to determine factors predicting the progression of PTC under AS. METHODS: A systematic search was performed in January 2022 using PubMed, Embase, Google Scholar, Web of Science, and ScienceDirect. PRISMA guidelines were used by multiple reviewers to extract study characteristics (author name, publication date, journal name, country, institution, and study design), as well as main outcomes and measures. A combination of utilization of thyroid replacement therapy, baseline tumor size and volume, follow-up tumor size and volume, and the presence of lymph node metastasis and its distribution, as well as surveillance duration, were the main measures of this study. RESULTS: Nine studies with 4166 patients were included, of which 354 showed tumor progression during AS (15 %; 95%CI = 7 % - 23 %). The average follow-up period was 41.58 months. The mean tumor maximum diameter was 8.54 mm (95%CI = 7.04-10.03). Tumor progression was most commonly secondary to an increase in volume by ≥50 % (75 %; 95%CI = 68 % - 80 %), then increase in diameter by ≥3 mm (41 %; 95%CI = 13 % - 76 %), and finally the development of lymph node metastasis (13 %; 95%CI = 9 % - 19 %). Approximately only 2 % of all patients thus developed new lymph node metastasis. Patient age, sex, and tumor size were not associated with higher risks of tumor progression. 12 % of AS patients eventually underwent surgery, though only 40 % (95%CI = 27 % - 53 %) of these patients displayed tumor progression. CONCLUSIONS: Our meta-analysis determined a tumor progression rate of 15 % in patients who underwent AS management, 13 % of which (2 % of all patients) developed lymph node metastasis. We found no protective or risk factors for tumor progression, and that almost half of all patients who underwent delayed surgery did so for reasons other than tumor progression. While not biopsying small (<1 cm) or very low suspicious nodules is already recommended, AS may be an appropriate treatment option in patients appropriately counseled, considering the low risk of advanced tumor progression but also the considerable patient population who fail to adhere to treatment. Alternatively, in aim of preventing overtreatment in patients who would rather take proactive measures against their low-risk carcinoma, minimally-invasive ablation techniques may be an attractive option.

A combination of computed tomography scan and ultrasound provides optimal detection of cervical lymph node metastasis in papillary thyroid carcinomas: A systematic review and meta-analysis.

BACKGROUND: Lymph node metastasis (LNM) in patients with papillary thyroid carcinoma (PTC) is common. This meta-analysis assesses the diagnostic accuracy of computed tomography (CT), ultrasound (US), and CT + US in detecting central and lateral LNM. METHODS: A systematic review and meta-analysis was performed by searching PubMed, Embase, and Cochrane for studies published up to April 2022. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) were calculated. The area under the curve (AUC) for summary receiver operating curves (sROC) were compared. RESULTS: The study population included 7902 patients with a total of 15 014 lymph nodes. Twenty-four studies analyzed the sensitivity of the overall neck region in which dual CT + US imaging (55.9%) had greater sensitivities (p < 0.001) than either US (48.4%) or CT (50.4%) alone. The specificity of US alone (89.0%) was greater (p < 0.001) than CT alone (88.5%) or dual imaging (86.8%). The DOR for dual CT + US imaging was greatest (p < 0.001) at 11.134, while the AUCs of the three imaging modalities were similar (p > 0.05). Twenty-one studies analyzed the sensitivity of the central neck region in which both CT (45.8%) and CT + US imaging (43.4%) had greater sensitivities (p < 0.001) than US alone (35.3%). The specificity of all three modalities was higher than 85%. The DOR for CT (7.985) was greater than US alone (4.723, p < 0.001) or dual CT + US imaging (4.907, p = 0.015). The AUC of both CT + US (0.785) and CT alone (0.785) were significantly greater (p < 0.001) than US alone (0.685). Of the 19 studies that reported lateral LNM, CT + US imaging sensitivity (84.5%) was higher than CT alone (69.2%, p < 0.001) and US alone (79.7%, p = 0.038). The specificity of all imaging techniques was all greater than 80.0%. CT + US imaging DOR (35.573) was greater than CT (20.959, p = 0.024) and US (15.181, p < 0.001) individually. The AUC of independent imaging was high (CT: 0.863, US: 0.858) and improved significantly when combined (CT + US: 0.919, p = 0.024 and p < 0.001, respectively). CONCLUSIONS: We report an up-to-date analysis elucidating the diagnostic accuracy of LNM detection by either CT, US, or in combination. Our work suggests dual CT + US to be the best for overall detection of LNM and CT to be preferable in detecting central LNM. The use of either CT or US alone may detect lateral LNM with acceptable accuracy, yet dual imaging (CT + US) significantly improved detection rates.

Comparison of Medical Management versus Parathyroidectomy in Patients with Mild Primary Hyperparathyroidism: A Meta-Analysis.

BACKGROUND: Parathyroidectomy is the definitive cure for patients with primary hyperparathyroidism (pHPT) and has an annual prevalence of 0.2-1% in the United States. Some patients with mild disease are medically managed effectively using calcium-lowering medications and drugs against complications such as osteoporosis; however, many maintain a persistently high calcium level that negatively impacts their skeletal, renal, and psychogenic systems over the long term. This meta-analysis aims to compare the outcomes of medical management versus parathyroidectomy in patients with mild pHPT. STUDY DESIGN: This meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science by two teams of investigators. Analysis was run using R packages. RESULTS: A total of 12 publications including seven randomized control, two prospective, and three retrospective trials with a total of 1346 patients were included for analysis. The average follow-up for all patients was 41 ± 23.8 months. Demographics, pre-treatment calcium, PTH, and bone mineral density (BMD) were similar between the medical (N = 632) and surgical (N = 714) cohorts. Post-treatment calcium and PTH levels were significantly higher in the medical cohort (10.46 vs. 9.39, p < 0.01), (106.14 vs. 43.25, p = 0.001), respectively. Interestingly, the post-treatment PTH in the medical cohort increased when compared to pre-treatment (83.84 to 106.14). Patients in the medical cohort had lower BMD in lumbar (0.48 g/cm2; OR = 0.42, 95% CI = 0.21, 0.83), femoral (0.48; OR = 0.42, 95% CI = 0.29, 0.61), and hip (0.61; OR = 0.33, 95% CI = 0.13, 0.85). Incidences of fracture, nephrolithiasis, cardiovascular death, or overall mortality were not significantly different between the cohorts. CONCLUSIONS: The present study is the most comprehensive meta-analysis on mild pHPT to date. Our findings reflect that parathyroidectomy is the superior option in the treatment of mild pHPT patients as opposed to medical management.

Radiofrequency ablation of an intrathyroidal parathyroid adenoma with intraoperative parathyroid hormone monitoring: a case report of a novel technique.

Background: Primary hyperparathyroidism (PHPT) is classically treated by conventional parathyroidectomy, an open neck surgery. Radiofrequency ablation (RFA) has been shown as a safe minimally-invasive alternative to parathyroidectomy for the management of PHPT and has been shown to be effective in 60-90% of cases. Here, we present a patient successfully treated for persistent PHPT by RFA with simultaneous intraoperative parathyroid hormone (IOPTH) monitoring. Case Description: A 51-year-old female with a past medical history of resistant hypertension, hyperlipidemia, and vitamin D deficiency presented to our endocrine surgery clinic with PHPT. Neck ultrasound (US) localized a 0.79 cm lesion suggestive of a parathyroid adenoma. Parathyroid exploration resulted in the excision of two masses. IOPTH levels dropped from 259.9 to 204.7 pg/mL. No ectopic parathyroid tissue was found. Three-month follow-up demonstrated elevated calcium levels, suggesting persistent disease. A repeat neck US one-year post operation localized a suspicious hypoechoic sub-centimeter thyroid nodule, which was subsequently determined to be an intrathyroidal parathyroid adenoma. The patient elected to proceed with RFA with IOPTH monitoring, citing concern for increased risk of redo open neck surgery. Operation pursued without complication and IOPTH levels dropped from 270 to 39.1 pg/mL. The patient's only three-day post-operative complaints, occasional numbness and tingling, were completely resolved by her three-month follow up. The patient had normal PTH and calcium levels at seven months post-operation visit and was without complaint. Conclusions: To our best knowledge, this is the first reported case of RFA with IOPTH monitoring used to manage a parathyroid adenoma. Our work adds to the growing literature suggesting minimally-invasive techniques, such as RFA with IOPTH, as a potential management option for treating parathyroid adenomas.

The Impact of Medicaid Expansion on Head and Neck Malignancies Presentation and Survival.

OBJECTIVE: Under the Affordable Care Act (ACA), Medicaid expansion became effective in states that have adopted it. We aim to examine its impact on head and neck cancers. METHODS: A retrospective study that utilizes the Surveillance, Epidemiology, and End Results database, 2010-2016. Study population included patients with head and neck squamous cell carcinoma (HNSCC), differentiated thyroid carcinoma, and head and neck cutaneous melanoma. The objective is to examine disease-specific survival before and after Medicaid expansion. RESULTS: In states that adopted Medicaid expansion, the ratio of Medicaid: uninsured patients increased from 3:1 to 9:1 (p < 0.001). In states that did not adopt Medicaid expansion, the ratio increased from 1:1 to 2:1 (p < 0.001), making the increase in Medicaid coverage in states that adopted the expansion significantly higher (p < 0.001). Patients diagnosed with HNSCC before the expansion had worse survival (hazard ratio [HR]: 1.24, 95% confidence interval: 1.11, 1.39, p < 0.001) in states that adopted Medicaid expansion. CONCLUSIONS: Early data indicate that implementation of ACA improved disease-specific survival of patients with HNSCC. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1409-1414, 2023.

Hashimoto's Thyroiditis: A Protective Factor against Recurrence in BRAF-Wild Type Differentiated Thyroid Carcinoma.

A recent work analyzing the concomitant factors BRAF mutation (risk factor) and Hashimoto's thyroiditis (HT) (protective factor) found that the presence of HT reduced lymph node metastasis in BRAF-mutated papillary thyroid carcinoma. Whether this notion is upheld with respect to disease recurrence and differentiated thyroid carcinoma (DTC), however, is unknown. We aimed to investigate the effect of underlying HT in DTC patients and its influence on recurrence with a specific emphasis in BRAF-mutated tumors. A total of 469 patients were included. Patients were stratified according to BRAF and HT status. Multivariate regression analysis was conducted to determine protective and risk factors of disease recurrence in patients with DTC. HT was associated with less-aggressive carcinomas including more frequent microcarcinomas (HT: 45.0% vs. no-HT: 34.0%, p = 0.02), less lymph node involvement (HT: 16.4% vs. no-HT: 26.1%, p = 0.02), and less disease recurrence (HT: 2.9% vs. no-HT: 11.9%, p = 0.002). BRAF mutation was also significantly associated with higher rates of lymph node involvement (BRAF-mutant: 41.9% vs. BRAF-wild type: 14.6%, p < 0.001) and almost two times the rate of recurrence (BRAF-mutant: 14.9% vs. BRAF-wild type: 6.5%, p = 0.004). Underlying HT was the only protective factor determined, reducing the odds of developing recurrence by 70% (HR: 0.30, 95%CI: 0.11-0.88). In the BRAF-wild type cohort, regression analysis continued to determine HT as a protective factor (p = 0.03). However, in the BRAF-mutant cohort, HT was no longer an independent protective factor (p = 0.20) against recurrence. Sub-group regression analysis, including PTC patients, similarly found HT as a protective factor only in BRAF-wild type patients (p = 0.039) and not BRAF-mutant (p = 0.627). The presence of underlying HT is associated with less aggressive tumors and is an independent protective factor against DTC recurrence, reducing the risk by 70%. HT remains a protective factor in BRAF-wild type carcinoma, but not in patients with BRAF-mutant carcinoma. HT may potentially be considered as a parameter which enhances American Thyroid Association patient risk stratification.

Diagnostic Performance of Afirma and Interpace Diagnostics Genetic Testing in Indeterminate Thyroid Nodules: A Single Center Study.

Indeterminate thyroid nodules (ITN) represent 20-30% of biopsied nodules, with a 10-60% risk of malignancy. Molecular testing can stratify the risk of malignancy among ITNs, and subsequently reduce the need for unnecessary diagnostic surgery. We aimed to assess the performance of these molecular tests at a single institution. Patients with Bethesda III, IV, and V nodules with Afirma and Interpace Diagnostics genetic testing data from November 2013 to November 2021 were included. Three cohorts were formed, including GSC + XA, ThyGeNEXT + ThyraMIR, and GSC + GEC. Statistical analysis determined the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic odds ratio (DOR), and accuracy of each type of testing. The PPV of nodules undergoing genetic testing by ThyGeNEXT + ThyraMIR (45.00%, 95%CI: 28.28-62.93%, p = 0.032) and GSC + XA (57.14%, 95%CI: 29.32-81.08%, p < 0.001) were superior to that of GEC + GSC (30.72%, 95%CI: 26.83-34.90%). The NPV was above 85% in all cohorts, suggesting overall suitable rule-out tests. The Afirma platform (GSC + XA) had the highest NPV at 96.97%. The overall accuracy for nodules undergoing ThyGeNEXT + ThyraMIR was 81.42% (95%CI: 73.01-88.11%, p < 0.001). A total of 230 patients underwent thyroidectomy, including less than 60% of each of the ThyGeNEXT + ThyraMIR and GSC + XA cohorts. Specifically, only 25% of patients in the GSC + XA cohort underwent surgery, considerably decreasing the rate of unnecessary surgical intervention. Sub-group analysis, including only patients with surgical pathology, found that PPV tended to be higher in the GSC + XA cohort, at 66.67% (95%CI: 37.28-87.06%), as compared to the ThyGeNEXT + ThyraMIR cohort, at 52.94% (95%CI: 35.25-69.92%). The Afirma genetic testing platform GSC + XA outperformed the other platforms with regards to both PPV and NPV and decreased the rate of surgery in patients with ITNs by 75%, significantly preventing unnecessary surgical intervention.

The beavertail modified radial forearm free flap: Retrospective review of a versatile technique to increase flap bulk in the head and neck.

OBJECTIVE: Utilization of free tissue transfers in head and neck reconstruction has greatly increased due to their dependability and reliability. Anterolateral thigh (ALT) and rectus abdominus (RA) free flaps may provide too much soft tissue bulk, especially in patients with a large body habitus. A radial forearm free flap (RFFF) may be modified with a "beaver tail" (BT), which provides a flap whose bulk may be tailored to a defect. The purpose of this paper is to describe the technique, how it can be used for a variety of defects and the outcomes of these reconstructions. METHODS: A retrospective review of prospectively collected data was performed at single tertiary care center between 2012 and 2022. BT-RFFF was designed by leaving a fibroadipose tail vascularized to branches of the radial artery or separated from the vascular pedicle and left attached to the proximal portion of the skin paddle. Functional outcomes, tracheostomy dependence, and gastrostomy tube (G-tube) dependence as well as complications were determined. RESULTS: Fifty-eight consecutive patients undergoing BTRFFF were included. Defects reconstructed included: oral tongue and/or floor of mouth 32 (55%), oropharynx 10 (17%), parotid 6 (10%), orbit 6 (10%), lateral temporal bone 3 (5%), and mentum 1 (2%). Indications for BTRFF were: need for bulk when the ALT and RA were too thick (53%) and need for a separate subcutaneous flap for contouring or deep defect lining (47%). Complications directly related to beavertail included a widened forearm scar (100%), wrist contracture (2%) partial flap loss (2%), and flap loss requiring a revision flap (3%). Ninety-three percent of patients with oral/oropharyngeal defects and 12-month follow-up tolerated oral intake without aspiration and 76% were tube-independent. Ninety-three percent were tracheostomy-free at last follow-up. CONCLUSION: The BTRFF is a useful tool for reconstructing complex 3D defects requiring bulk where an ALT or rectus would otherwise provide too much bulk.

Cardiovascular Health by Graves' Disease Management Modality - Surgery Versus Radioactive Iodine Versus Antithyroid Medications: A Network Meta-Analysis.

INTRODUCTION: Graves' disease is an autoimmune disorder of the thyroid gland associated with the overproduction of thyroid hormones. Excess secretion of thyroid hormones leads to cardiovascular consequences. Treatment options include antithyroid medications (ATM), radioactive iodine (RAI) ablation, and total thyroidectomy. We examined the cardiovascular outcomes following Graves' disease management modality. METHODS: A systematic search was performed up to September 22nd, 2021, using PubMed, EMBASE, and Web of Science databases. We conducted a network meta-analysis analyzing cardiovascular outcomes of interest, including congestive heart failure (CHF), arrhythmia, atrial fibrillation (AF), and hypertension. RESULTS: Three studies were included in this analysis totaling 6700 patients with Graves' disease, of which 74% were female. The mean age was 44.34 y. When compared to pretreatment, management options lowered the risk of maintaining arrhythmia 81% with surgery (relative risk [RR] = 0.19; 95% confidence interval [CI] = 0.12 to 0.31), 67% with ATM (RR = 0.33; 95% CI = 0.23 to 0.49), and 50% with RAI (RR = 0.50; 95% CI = 0.13 to 1.95). Risk of maintaining CHF was reduced 80% with surgery (RR = 0.20; 95% CI = 0.08 to 0.49), 41% with ATM (RR = 0.59; 95%CI = 0.52 to 0.67), and only 7% with RAI (RR = 0.93; 95%CI = 0.68 to 1.26). Treatment-ranking analysis found all parameters, including CHF, arrhythmia, AF, and hypertension, to be in favor of surgical treatment over medical treatment and RAI ablation. CONCLUSIONS: This is the first network meta-analysis analyzing the cardiovascular outcomes in Graves' disease patients by treatment option. Our study demonstrated that surgery is superior to RAI and medical treatment.

The Effect of Patient Positioning on Intraoperative Neuromonitoring During Thyroid and Parathyroid Surgery.

BACKGROUND: Intraoperative neuromonitoring (IONM) has been accepted as a routine adjunct among surgeons who perform thyroid and parathyroid surgeries. Thyroid and parathyroid surgeries use various patient positioning strategies that have poorly understood effects on IONM. The aim of this study was to compare IONM signals between the transaxillary and transcervical approaches. METHODS: In this retrospective cohort study, we evaluated 463 adult patients who underwent a total of 502 procedures. The procedures performed included total thyroidectomy, right or left hemithyroidectomy, and parathyroidectomy. Vagus nerve and recurrent laryngeal nerve (RLN) latency and amplitude measurements were analyzed intra-operatively. The distances between the vagus nerve and the trachea were measured via ultrasound during transaxillary procedures. RESULTS: Compared to the transcervical approach, the right vagus nerve latency was significantly decreased in the transaxillary approach. Transaxillary surgery was not associated with increased latency or decreased amplitude on IONM. The distance between the vagus nerve and trachea was significantly decreased post-positioning during transaxillary approaches. DISCUSSION: Despite differences in patient positioning, a transaxillary approach was not associated with increased stress on the vagus nerve or RLN, according to IONM data. The decreased right vagus nerve latency associated with a transaxillary approach highlights the importance of considering patient positioning and laterality while interpreting IONM data.

Presentation and Outcomes of Otolaryngologic Surgeries in Patients With Mental Illness History.

BACKGROUND: Describe the epidemiology and characteristics of patients with a history of mental illness undergoing otolaryngologic procedures. METHODS: A retrospective cross-sectional analysis utilizing the Nationwide Readmissions Database, 2010 to 2015. The study sample included adult (≥18 years) patients undergoing otolaryngologic procedures. RESULTS: A total of 146 182 patients were included, 18.3% with mental illness history. The prevalence of patients who required otolaryngologic surgeries with history of mental illness increased significantly from 14.9% in 2010 to 25.0% in 2015 (P < .001). Mental illness diagnoses included: depression (6.9%), anxiety (5.8%), alcohol dependence (4.2%), substance dependence (2.9%), bipolar disorder (1.4%), memory disorders (1.2%), delusional disorders (0.6%), self-harm (0.1%). Patients with a history of mental illness were more likely to be <65 years, female, and have multiple comorbidities (P < .05 each). Patients with history of mental illness had a higher risk of complications [OR:1.59, 95% CI:1.50,1.69, P < .001]. CONCLUSIONS: Patients with a history of mental illness are increasingly encountered in otolaryngology service. This study provides an epidemiological perspective that warrants increasing clinical investigation of this subpopulation.