National Trends and Outcomes in the Operative Management of Thyroid Storm.

BACKGROUND: Thyroid storm is a rare but potentially lethal manifestation of thyrotoxicosis. Guidelines recommend nonoperative management of thyroid storm, but thyroidectomy can be performed if patients fail medical therapy or need immediate resolution of the storm. Outcomes of thyroidectomy for management of thyroid storm remain ill-defined. METHODS: Using the National Inpatient Sample from 2016 to 2020, a retrospective analysis was conducted of patients admitted with thyroid storm. Outcomes of interest included operative complications and mortality. Multivariable logistic regression was performed to assess factors associated with receiving thyroidectomy and mortality. RESULTS: An estimated 16,175 admissions had a diagnosis of thyroid storm. The incidence of thyroid storm increased from .91 per 100,000 people in 2016 to 1.03 per 100,000 people in 2020, with a concomitant increase in mortality from 2.9% to 5.3% (P < .001). Operative intervention was pursued in 635 (3.9%) cases with a perioperative complication rate of 30%. On multivariable regression, development of acute decompensated heart failure (adjusted odds ratio [AOR] 1.66, 95% Confidence Interval [CI] 1.03-2.68, P = .037) and acute renal failure (AOR 2.10, 95% CI 1.17-3.75, P = .013) increased odds of receiving surgery. The same multivariable model did not show a significant association between thyroidectomy and mortality. DISCUSSION: The incidence of thyroid storm and associated mortality increased during the study period. Thyroidectomy is rarely performed during the same admission, with an overall perioperative complication rate of 30% and no effect on mortality. Patients with acute decompensated heart failure and renal failure were more likely to receive an operative intervention.

From Bench-to-Bedside: How Artificial Intelligence Is Changing Thyroid Nodule Diagnostics.

CONTEXT: Use of artificial intelligence (AI) to predict clinical outcomes in thyroid nodule diagnostics has grown exponentially over the past decade. The greatest challenge is in understanding the best model to apply to one's own patient population, and how to operationalize such a model in practice. EVIDENCE ACQUISITION: A literature search of PubMed and IEEE Xplore was conducted for English language publications between January 1, 2015 and January 1, 2023 studying diagnostic tests on suspected thyroid nodules that utilized AI. We excluded articles without prospective or external validation, non-primary literature, duplicates, focused on non-nodular thyroid conditions, not using AI, and those incidentally utilizing AI in support of an experimental diagnostic outside standard clinical practice. Quality was graded by Oxford level of evidence. EVIDENCE SYNTHESIS: A total of 61 studies were identified; all performed external validation, sixteen studies were prospective, and 33 compared a model to physician prediction of ground truth. Statistical validation was reported in 50 papers. A diagnostic pipeline was abstracted, yielding five high-level outcomes: (1) nodule localization, (2) ultrasound risk score, (3) molecular status, (4) malignancy, and (5) long-term prognosis. Seven prospective studies validated a single commercial AI; strengths included automating nodule feature assessment from ultrasound and assisting the physician in predicting malignancy risk, while weaknesses included automated margin prediction and inter-observer variability. CONCLUSIONS: Models predominantly used ultrasound images to predict malignancy. Of four FDA-approved products, only S-Detect was extensively validated. Implementing an AI model locally requires data sanitization and re-validation to ensure appropriate clinical performance.

Extent of Surgery for Medullary Thyroid Cancer and Prevalence of Occult Contralateral Foci.

Importance: Standard treatment for patients with medullary thyroid cancer (MTC) consists of total thyroidectomy with central neck dissection, but the rationale for bilateral surgery in patients with unilateral disease on ultrasonography remains unclear. Objective: To determine the presence of occult contralateral disease (lesions not seen on preoperative ultrasonography) in patients with MTC as a rationale for total thyroidectomy. Design, Setting, and Participants: This multi-institutional, retrospective cohort study was conducted from September 1998 to April 2022 in academic medical centers and included patients with MTC who underwent thyroidectomy with preoperative imaging. Main Outcomes and Measures: The primary end point was the prevalence of sonographically occult foci of MTC in the contralateral lobe among patients with sporadic MTC. Results: The cohort comprised 176 patients with a median age at diagnosis of 55 years (range, 2-87 years), 69 (57.6%) of whom were female. Genetic testing was performed in 109 patients (61.9%), 48 (27.5%) of whom carried germline RET variants. Initial surgical management consisted of total thyroidectomy (161 [91.0%]), lobectomy followed by completion thyroidectomy (7 [4.0%]), and lobectomy alone (8 [4.5%]). Central and lateral neck dissections were performed as part of initial therapy for 146 patients (83.1%). In the entire cohort of 176 patients, 46 (26.0%) had contralateral foci disease and 9 (5.1%) had occult contralateral foci that were not identified on preoperative ultrasonography. Among 109 patients who underwent genetic testing, 38 (34.9%) had contralateral disease, 8 (7.3%) of whom had occult contralateral disease not seen on preoperative ultrasonography. Patients with sporadic MTC experienced a 95.7% reduction in the odds of having a focus of MTC in the contralateral lobe compared with patients with a germline RET variant (odds ratio, 0.043; 95% CI, 0.013-0.123). When adjusting for age, sex, tumor size, and lymph node involvement, the odds ratio of having contralateral MTC in patients with sporadic disease was 0.034 (95% CI, 0.007-0.116). Among patients who underwent lobectomy alone with postoperative calcitonin levels, 5 of 12 (41.7%) achieved undetectable calcitonin levels (<2.0 pg/mL; to convert to pmol/L, multiply by 0.292). Conclusions and Relevance: The results of this cohort study suggest that a staged approach involving initial thyroid lobectomy could be considered in patients with sporadic MTC and no contralateral ultrasonography findings, with no further surgery if calcitonin levels became undetectable. Further work using prospective randomized clinical trials to evaluate lobectomy as a biochemical cure in patients presenting with unilateral disease is warranted.

Rural-Urban Disparities in the Continuum of Thyroid Cancer Care: Analysis of 92,794 Cases.

Objective: Rurality is associated with higher incidence and higher disease-specific mortality for most cancers. Outcomes for rural and ultrarural ("frontier") patients with thyroid cancer are poorly understood. This study aimed to identify actionable deficits in thyroid cancer outcomes for rural patients. Methods: We queried linked California Cancer Registry and California Office of Statewide Health Planning and Development databases for patients diagnosed with thyroid cancer (1999-2017). We analyzed time from disease stage at diagnosis, time from diagnosis to surgery, receipt of appropriate radioactive iodine ablation, surveillance status, and overall and disease-specific mortality for urban, rural, and frontier patients. Cox and logistic regression models controlled for clinical and demographic covariates a stepwise manner. All incidence figures are expressed as a proportion of newly diagnosed cases. Results: Our cohort comprised 92,794 subjects: (65,475 women [70.6%]; mean age 50.0 years). Compared to urban patients, rural and frontier patients were more likely to be American Indian, White, uninsured, and from lower quintiles of socioeconomic status (p < 0.01). Distant disease at diagnosis was more common in rural (56.0 vs. 50.4 cases per 1000 new cases, p < 0.01) and frontier patients (80.9 vs. 50.4 per 1000, p < 0.01) compared to urban patients. The incidence of medullary thyroid cancer was greater in rural patients (17.9 vs. 13.6 cases per 1000, p < 0.01) and frontier patients (31.0 vs. 13.6 per 1000, p < 0.01) compared to urban patients. The incidence of anaplastic thyroid cancer was higher in frontier versus urban patients (15.5 vs. 7.1 per 1000, p < 0.01). When compared to urban patients, rural and frontier patients were more often lost to follow-up (odds ratio [OR] 1.69 [confidence interval, CI 1.54-1.85], and OR 3.03 [CI 1.89-5.26], respectively) and had higher disease-specific mortality (OR 1.18 [CI 1.07-1.30], and OR 1.92 [CI 1.22-2.77], respectively). Rural and frontier residence was independently associated with being lost to follow-up, suggesting that it is a key driver of disparities. Conclusion: Compared to their urban counterparts, rural and frontier patients with thyroid cancer present with later-stage disease and experience higher disease-specific mortality. They also are more often lost to follow-up, which presents an opportunity for targeted outreach to reduce the observed disparities in outcomes.

Diagnostic performance of molecular testing in indeterminate (Bethesda III and IV) thyroid nodules with Hürthle cell cytology.

BACKGROUND: Indeterminate thyroid nodules with Hürthle cell cytology remain a diagnostic challenge. The low benign call rate and positive predictive value of first-generation molecular tests precluded their use to rule out malignancy. We examined the diagnostic performance of current tests. METHOD: This subset analysis of our prospective randomized trial compared the benign call rate and positive predictive value of Afirma Gene Sequencing Classifier and Thyroseq v3 in Bethesda III and IV nodules with Hürthle cell cytology. Molecular test samples were obtained at initial fine-needle aspiration (8/2017-7/2022) and reflexively sent for processing. RESULTS: Molecular testing was performed on 140 Hürthle cell nodules. Of 79 nodules tested with the Afirma Gene Sequencing Classifier, the benign call rate was 84% (66/79). Nine of 66 nodules with benign results were resected, with no malignancies. Twelve of 13 nodules with suspicious results were resected, revealing 3 malignancies-2 papillary thyroid carcinomas and one Hürthle cell carcinoma (positive predictive value 25%). Of 61 nodules tested with Thyroseq v3, the benign call rate was 56% (34/61; (P < .01 versus Afirma Gene Sequencing Classifier). Five of 34 nodules with negative results were resected, with no malignancies. Nineteen of 27 nodules with positive results were resected, revealing 3 malignancies-2 papillary thyroid carcinomas and 1 Hürthle cell carcinoma (positive predictive value 16%). CONCLUSION: The high benign call rate of current molecular tests in Hürthle cell nodules strengthens their value in enabling patients to avoid surgery.

Disparities in Initial Thyroid Cancer Care by Hospital Treatment Volume: Analysis of 52,599 Cases in California.

Background: Racially minoritized patients with thyroid cancer are less likely to receive high-quality and guideline-concordant care. Inaccessibility of high-volume centers may contribute to inequalities in thyroid cancer outcomes. This study sought to understand the extent to which access to higher volume thyroid cancer centers is associated with patient outcomes. Methods: We queried linked California Cancer Registry and California Office of Statewide Health Planning and Development databases for thyroid cancer patients who received thyroid surgery between 1999 and 2017. Hospitals were stratified by their median annual volume of thyroid cancer operations: ultra-low volume (0-5 cases/year), low-volume (6-25 cases/year), mid-volume (26-50 cases/year), and high-volume (>50 cases/year). We analyzed the rates of complications, rates of reoperation for cancer recurrence, use of radioactive iodine (131I), and mortality by median hospital volume of thyroid surgery. A multivariable regression controlled for high-risk tumor features. Differences in access by center volume were assessed based on patient demographics. Results: We studied 52,599 thyroid cancer patients who underwent thyroidectomy. Patients who underwent thyroidectomy at ultra-low volume centers were more likely to undergo reoperations for recurrent/persistent disease compared with patients at low- (odds ratio [OR] 1.17 [CI 1.02-1.35]), mid- (OR 1.25 [CI 1.06-1.46]), and high-volume centers (OR 1.26 [CI 1.03-1.56]). Patients who received thyroid operations at ultra-low volume centers were also less likely to receive guideline-concordant 131I ablation compared with patients at higher volume centers (OR 0.77 [CI 0.72-0.82]). A pair-wise comparison between all volume categories for all outcomes revealed no statistically significant differences in outcomes between low-, mid-, or high-volume centers. Only ultra-low volume centers had significantly higher rates of adverse outcomes. Ultra-low volume centers were disproportionately accessed by women (p < 0.05), Hispanic, Asian/Pacific Islander, and American Indian people (p < 0.01), those from the lowest three quintiles of socio-economic status (p < 0.01), and the uninsured and those on Medicaid or Medicare (p < 0.01) when compared with higher volume centers. Conclusions: Patients receiving thyroid cancer surgery at centers performing ≤5 such operations per year were more likely to require reoperation for recurrent/persistent disease and less likely to receive appropriate 131I ablation. Ultra-low volume centers served higher proportions of socially and economically marginalized communities.

Prognostic Value of Preoperative Molecular Testing and Implications for Initial Surgical Management in Thyroid Nodules Harboring Suspected (Bethesda V) or Known (Bethesda VI) Papillary Thyroid Cancer.

Importance: Molecular testing is commonly used in the diagnosis of thyroid nodules with indeterminate cytology. The role of molecular testing in prognosticating oncologic outcomes in thyroid nodules with suspicious or malignant cytology is unclear. Objective: To determine whether molecular profiling of Bethesda V (suspicious for thyroid cancer) and VI (thyroid cancer) nodules is associated with improved prognostication and whether it may inform initial treatment. Design, Setting, and Participants: This retrospective cohort study included consecutive patients with Bethesda V or VI nodules who underwent surgery, with histopathology showing differentiated thyroid cancer, between May 1, 2016, and July 31, 2019 in the University of California, Los Angeles health system. Data were analyzed between April 2, 2021, and January 18, 2023. Exposures: Masked ThyroSeq, version 3 molecular analysis after completion of initial treatment and acquisition of follow-up data. Main Outcomes and Measures: Structural disease persistence or recurrence, distant metastasis, and recurrence-free survival were assessed using ThyroSeq Cancer Risk Classifier (CRC) molecular risk groups (low, RAS-like; intermediate, BRAF-like; high, combination of BRAF/RAS plus TERT or other high-risk alterations) using Cox proportional hazards regression models. Results: In 105 patients with papillary thyroid cancer (median [IQR] follow-up, 3.8 [3.0-4.7] years), ThyroSeq identified genomic alterations in 100 (95%) samples (6 [6%] low risk, 88 [88%] intermediate risk, and 6 [6%] high risk; median [IQR] age, 44 [34-56] years; 68 [68%] female and 32 [32%] male). No patients with low-risk or negative results experienced recurrence. Of the 88 patients with intermediate risk, 6 (7%) experienced local recurrence, with 1 of them also developing distant metastasis. The 6 patients with high risk (all with BRAF V600E plus TERT mutation) underwent total thyroidectomy followed by radioactive iodine (RAI) ablation. Four patients with high risk (67%) experienced local recurrence, with 3 of them also developing distant metastasis. Thus, patients with high-risk alterations were more likely to experience persistence or recurrence and distant metastasis than patients with intermediate risk. In a multivariable analysis incorporating patient age, sex, cancer size, ThyroSeq molecular risk group, extrathyroidal extension, lymph node positivity, American Thyroid Association risk, and RAI ablation, only cancer size (hazard ratio, 1.36; 95% CI, 1.02-1.80) and ThyroSeq CRC molecular risk group (high vs intermediate and low: hazard ratio, 6.22; 95% CI, 1.04-37.36) were associated with structural recurrence. Conclusions and Relevance: Among the 6% of patients with high-risk ThyroSeq CRC alterations in this cohort study, the majority experienced recurrence or distant metastasis despite initial treatment with total thyroidectomy and RAI ablation. In contrast, patients with low- and intermediate-risk alterations had a low recurrence rate. Preoperative knowledge of molecular alteration status at diagnosis may allow for deescalation of initial surgery and refining of the intensity of postoperative surveillance in patients presenting with Bethesda V and VI thyroid nodules.

Patient Preference in Physician Decision-Making for Patients With Low- to Intermediate-Risk Differentiated Thyroid Cancer.

This survey study describes the association between patient preference and physician decision-making in thyroid cancer.

Management of small bowel obstruction and systematic review of treatment without nasogastric tube decompression.

Background: Small bowel obstruction (SBO) is common and its management has evolved in recent years. Study design: The literature describing adhesive small bowel obstruction (aSBO) treatment was reviewed, and a formal systematic review was performed to identify publications reporting results of aSBO treatment without NGTs. Results: The annual rate of hospital admission for SBO in the US has increased, with 340,100 admissions in 2019 alone. SBO is usually treated with bowel rest, intravenous hydration and NGT placement. In recent years, water soluble contrast (WSC) has been used as a cathartic to simulate bowel function and may reduce hospital length of stay (HLOS) by 1.95 days (95%CI 0.56-3.3). There were 3 articles of the initial 1650 screened that reported outcomes of SBO treatment without NGTs. These articles included 759 patients, of whom 272 (36%) with aSBO were managed successfully without NGTs. When comparing outcomes to patients who did receive NGT decompression, there were no significant differences in operative rates (28.6% v 16.5%, risk ratio 1.34, 95% CI 1.0, 1.8). Mortality and rates of bowel resection were also not affected by NGT decompression (risk ratio 1.98, 95% CI 0.43, 9.10 and risk ratio 1.56, 95% CI 0.92, 2.65, respectively). Conclusion: SBO is a common disease process with increasing annual incidence. Use of WSC stimulates the bowel and may reduce HLOS. Modern aSBO treatment protocols should include NGT decompression with consideration of WSC administration. Selection of patients for treatment without NGT decompression requires further investigation.

Bethesda III and IV Thyroid Nodules Managed Nonoperatively After Molecular Testing With Afirma GSC or Thyroseq v3.

CONTEXT: Molecular testing has improved risk stratification and increased nonoperative management for patients with indeterminate thyroid nodules, but data on the long-term outcomes of current molecular tests Afirma Gene Sequencing Classifier (GSC) and Thyroseq v3 are limited. OBJECTIVE: To determine the rate of delayed operation and the false negative rate of the Afirma GSC and Thyroseq v3 in Bethesda III and IV thyroid nodules. METHODS: Prospective follow-up of a single center, randomized, clinical trial comparing the performance of Afirma GSC and Thyroseq v3 in the diagnosis of indeterminate thyroid nodules at the University of California, Los Angeles (UCLA). Consecutive participants who underwent thyroid biopsy in the UCLA health system with Bethesda III and IV cytology from August 2017 to November 2019. The main outcome measure was false negative rate of molecular testing. RESULTS: Of 176 indeterminate nodules with negative or benign molecular test results, 14 (8%) nodules underwent immediate resection, with no malignancies found on surgical pathology. Nonoperative management with active surveillance was pursued for 162 (92%) nodules with benign or negative test results. The median surveillance was 34 months (range 12-60 months), and 44 patients were lost to follow-up. Of 15 nodules resected during surveillance, 1 malignancy was found (overall false negative rate of 0.6%). This was a 2.7 cm minimally invasive Hurthle cell carcinoma that initially tested negative with Thyroseq v3 and underwent delayed resection due to sonographic growth during surveillance. CONCLUSIONS: The majority of Bethesda III/IV thyroid nodules with negative or benign molecular test results are stable over 3 years of follow-up. These findings support the high sensitivity of current molecular tests and their role in ruling out malignancy in indeterminate thyroid nodules.

HCC EV ECG score: An extracellular vesicle-based protein assay for detection of early-stage hepatocellular carcinoma.

BACKGROUND AND AIMS: The sensitivity of current surveillance methods for detecting early-stage hepatocellular carcinoma (HCC) is suboptimal. Extracellular vesicles (EVs) are promising circulating biomarkers for early cancer detection. In this study, we aim to develop an HCC EV-based surface protein assay for early detection of HCC. APPROACH AND RESULTS: Tissue microarray was used to evaluate four potential HCC-associated protein markers. An HCC EV surface protein assay, composed of covalent chemistry-mediated HCC EV purification and real-time immuno-polymerase chain reaction readouts, was developed and optimized for quantifying subpopulations of EVs. An HCC EV ECG score, calculated from the readouts of three HCC EV subpopulations ( E pCAM + CD63 + , C D147 + CD63 + , and G PC3 + CD63 + HCC EVs), was established for detecting early-stage HCC. A phase 2 biomarker study was conducted to evaluate the performance of ECG score in a training cohort ( n  = 106) and an independent validation cohort ( n  = 72).Overall, 99.7% of tissue microarray stained positive for at least one of the four HCC-associated protein markers (EpCAM, CD147, GPC3, and ASGPR1) that were subsequently validated in HCC EVs. In the training cohort, HCC EV ECG score demonstrated an area under the receiver operating curve (AUROC) of 0.95 (95% confidence interval [CI], 0.90-0.99) for distinguishing early-stage HCC from cirrhosis with a sensitivity of 91% and a specificity of 90%. The AUROCs of the HCC EV ECG score remained excellent in the validation cohort (0.93; 95% CI, 0.87-0.99) and in the subgroups by etiology (viral: 0.95; 95% CI, 0.90-1.00; nonviral: 0.94; 95% CI, 0.88-0.99). CONCLUSION: HCC EV ECG score demonstrated great potential for detecting early-stage HCC. It could augment current surveillance methods and improve patients' outcomes.

Racial/ethnic disparities in thyroid cancer in California, 1999-2017.

BACKGROUND: Recent studies examining treatment disparities in thyroid cancer care found that appropriate use of surgery and radioactive iodine may be improving over time. METHODS: California Cancer Registry and California Office of Statewide Health Planning and Development data was evaluated for the effect of race on overall and disease-specific survival for thyroid cancer in California (1999-2017). Reoperation data was also examined. We hypothesized treatment and outcome disparities would persist between Black and white patients. RESULTS: Black patients with thyroid cancer had worse overall survival than white patients (p < 0.01). No difference was found in disease-specific survival between Black and white patients after adjusting for SES and health insurance status. Black patients underwent reoperation less frequently (1.4%) (HR = 0.70 [CI, 0.50-0.99], p < 0.05) than white patients (2.0%). CONCLUSIONS: SES and insurance type are drivers of disparities in thyroid cancer survival in Black patients. Addressing social determinants of health or healthcare access are paramount to addressing disparities in thyroid cancer between Black and white patients.

The Effect of Hyperosmolar Water-Soluble Contrast for the Management of Adhesive Small Bowel Obstruction: A Systematic Review and Meta-Analysis.

OBJECTIVE: To better understand the efficacy of water-soluble contrast (WSC) in the treatment of adhesive small bowel obstruction (SBO). BACKGROUND: Guidelines recommend using WSC to treat adhesive SBO nonoperatively by acting as a cathartic agent. The evidence supporting this practice is mixed. METHODS: A systematic review and meta-analysis of published articles describing the effect of WSC compared with control treatments was performed for the period of January 1, 1990 to November 1, 2021. Study quality was assessed using the Cochrane risk-of-bias and the Newcastle-Ottawa tools. The therapeutic effect of WSC was assessed by operative rates and hospital length of stay (HLOS) in nonsurgical patients. RESULTS: The initial search yielded 4879 articles, of which, 28 were selected for full text review. We identified 11 eligible randomized controlled trials (RCTs) which included 817 patients and 9 observational studies of 3944 patients. HLOS in nonsurgical patients decreased by 1.95 days (95% confidence interval: 0.56-3.3) in the RCTs and could not be assessed in the observational studies. WSC did not significantly affect operative rates in the RCTs (19.8% vs. 21.4%) but did reduce rates in the observational studies (11% vs. 16%, risk ratio: 0.56, 95% confidence interval: 0.39-0.82). CONCLUSION: WSC studies may reduce HLOS for patients who have SBO and do not require surgery. However, the current literature is heterogenous with considerable design limitations. High-quality RCTs are needed using standardized protocols to determine the full benefit of WSC for the management of SBO.

Perception of risk and treatment decisions in the management of differentiated thyroid cancer.

BACKGROUND AND OBJECTIVES: The recent de-escalation of care for differentiated thyroid cancer (DTC) has broadened the range of initial treatment options. We examined the association between physicians' perception of risk and their management of DTC. METHODS: Thyroid specialists were surveyed with four clinical vignettes: (1) indeterminate nodule (2) tall cell variant papillary thyroid cancer (PTC), (3) papillary thyroid microcarcinoma (mPTC), and (4) classic PTC. Participants judged the operative risks and likelihood of structural cancer recurrence associated with more versus less aggressive treatments. A logistic mixed effect model was used to predict treatment choice. RESULTS: Among 183 respondents (13.4% response rate), 44% were surgical and 56% medical thyroid specialists. Risk estimates and treatment recommendation varied markedly in each case. Respondents' estimated risk of 10-year cancer recurrence after lobectomy for a 2.0-cm PTC ranged from 1% to 53% (interquartile range [IQR]: 3%-12%), with 66% recommending lobectomy and 34% total thyroidectomy. Respondents' estimated 5-year risk of metastastic disease during active surveillance of an 0.8-cm mPTC ranged from 0% to 95% (IQR: 4%-15%), with 36% choosing active surveillance. Overall, differences in perceived risk reduction explained 10.3% of the observed variance in decision-making. CONCLUSIONS: Most of the variation in thyroid cancer treatment aggressiveness is unrelated to perceived risk of cancer recurrence.

Trends in Adjuvant External Beam Radiation Therapy for Nonanaplastic Thyroid Cancer in California, 2003-2017.

BACKGROUND: External beam radiation therapy (EBRT) is rarely used to treat patients with differentiated or medullary thyroid cancer. Although EBRT is generally administered to patients with high-risk or unresectable diseases, neither its indications for the use nor the associated outcomes are well-defined. We used a statewide cohort to assess the trends in EBRT use and postradiation outcomes in California. METHODS: A population-based study of patients within the California Cancer Registry who underwent EBRT after surgery for nonanaplastic thyroid cancer (2003-2017) was conducted. The primary outcome was the annual utilization rate of EBRT. The secondary outcomes included Kaplan-Meier analysis for cause-specific survival and identifying factors associated with improved survival after EBRT. RESULTS: Among the 57 607 patients with nonanaplastic thyroid cancer from 2003 to 2017, 344 (0.6%) patients received EBRT. EBRT was utilized in 0.4% of papillary, 1.1% of follicular, and 7.7% of medullary thyroid cancers in California. Overall, 99 (28.8%) patients treated with EBRT died of thyroid cancer. The 10-year cause-specific survival of all patients with thyroid cancer after EBRT was 61.5% (95% CI: 54.8%-69.1%) and that of patients without distant disease was 80.3% (95% CI: 73.5%-87.8%). The survival outcomes varied by tumor size, histology, disease stage, patient age at diagnosis, and the presence of extrathyroidal extension (P < .05). CONCLUSIONS: The use of adjuvant EBRT for nonanaplastic thyroid cancer remained stable and low in California from 2003 to 2017. The comparative efficacy of EBRT was not discernible in this study, but disease control appeared durable in select patients. Well-controlled observational studies and/or prospective studies are needed to better define which patients benefit from EBRT.

Short-term perioperative outcomes among patients with concurrent asymptomatic and mild SARS-CoV-2 infection: A retrospective, multicenter study.

BACKGROUND: Previous studies report high rates of postoperative morbidity and mortality among patients with SARS-CoV-2 (COVID-19). With routine preoperative screening, we are identifying an increasing number of patients with asymptomatic and mild COVID-19. Based on these prior studies, we hypothesized that patients with asymptomatic and mild COVID-19 infections have low perioperative morbidity and mortality. The purpose of this study was to determine the risk of perioperative morbidity and mortality associated with operations performed on patients diagnosed with asymptomatic or mild COVID-19. METHODS: A multicenter, retrospective study of patients with asymptomatic/mild SARS-CoV-2 (COVID-19) infection diagnosed within 8 days of surgery from March 2020 to February 2021. The primary outcome was 30-day mortality, and secondary outcomes included pulmonary complications and perioperative morbidity. The Chinese Center for Disease Control and Prevention criteria of COVID severity was used for categorization. RESULTS: The initial cohort included 53 patients. COVID-19 infection was detected preoperatively in 86.8%. At admission, 90.5% of patients were asymptomatic, 7.5% had mild COVID-19 symptoms, and 1.9% were unknown due to obtundation and later determined to be asymptomatic. Of the 53 cases, 35.8% were general surgical and 18.9% orthopedic; the remaining 54.7% were other surgical subspecialties. Overall mortality was 0%. New COVID-19 symptoms developed in 13.2% of patients postoperatively, with only 11.3% developing postoperative pulmonary complications. CONCLUSION: Postoperative morbidity and mortality rates were low among patients with asymptomatic and mild COVID-19. The risks of nonoperative management should be weighed against these operative risks in such patients with surgical indications.

Perioperative pain management for thyroid and parathyroid surgery: A systematic review.

INTRODUCTION: A growing body of evidence suggests that surgeons have historically over-prescribed opioid pain medications following thyroid and parathyroid surgery, thereby potentially contributing to the current US opioid epidemic. We reviewed the evidence supporting multimodal methods of pain control after cervical endocrine surgery. METHODS: Fifty-one randomized clinical trials, 9 prospective cohort studies, 7 retrospective studies/reviews, and 1 survey regarding pain management for cervical endocrine surgery were include. RESULTS: Most studies reported in-hospital pain scores and opioid consumption. Data on pain scores following discharge were limited. In several studies, the interventional dose was much greater than what is commonly used clinically. CONCLUSION: Several evidence-based, non-opioid interventions can be incorporated into a standardized pain management protocol following cervical endocrine surgery. Little is known regarding the effects of these interventions on post-discharge pain scores and patient quality of life during recovery.

Cost analysis of reflexive versus selective molecular testing for indeterminate thyroid nodules.

BACKGROUND: Molecular testing is now commonly used to refine the diagnosis of indeterminate thyroid nodules. The purpose of this study is to compare the costs of a reflexive molecular testing strategy to a selective testing strategy for indeterminate thyroid nodules. METHODS: A Markov model was constructed to estimate the annual cost of diagnosis and treatment of a real-world cohort of patients with cytologically indeterminate thyroid nodules, comparing a reflexive testing strategy to a selective testing strategy. Model variables were abstracted from institutional clinical trial data, literature review, and the Medicare physician fee schedule. RESULTS: The average cost per patient in the reflexive testing strategy was $8,045, compared with $6,090 in the selective testing strategy. In 10,000 Monte Carlo simulations, diagnostic thyroid lobectomy for benign nodules was performed in 2,440 patients in the reflexive testing arm, compared with 3,389 patients in the selective testing arm, and unintentional observation for malignant nodules occurred in 479 patients in the reflexive testing arm, compared with 772 patients in the selective testing arm. The cost of molecular testing had the greatest impact on overall costs, with $1,050 representing the cost below which the reflexive testing strategy was cost saving compared with the selective testing strategy. CONCLUSION: In this cost-modeling study, reflexive molecular testing for indeterminate thyroid nodules enabled patients to avoid unnecessary thyroid lobectomy at an estimated cost of $20,600 per surgery avoided.