Adenoma weight: the only predictive factor for multiple gland disease in primary hyperparathyroidism.

BACKGROUND: Predicting a multiple gland disease (MGD) in primary hyperparathyroidism (pHPT) remains challenging. This study aimed to evaluate predictive factors for MGD. METHODS: A retrospective chart review was performed of 1211 patients with histologically confirmed parathyroid adenoma or hyperplasia between 2007-2016. Localization diagnostics, laboratory parameters, and the weight of the resected parathyroid glands were evaluated concerning their predictive value of a multiple-gland disease. RESULTS: A number of 1111 (91.7%) had a single-gland disease (SGD), and 100 (8.3%) a multiple-gland disease (MGD). US and MIBI scans were comparable for either negative or positive adenoma localization and suspected MGD. While the PTH level was similar, the calcium level was higher in SGD (2.8 mmol/L versus 2.76 mmol/L, P=0.034). MGD had a significantly lower gland weight (0.78 g versus 0.31 g; P<0.001). A gland weight of 0.418 grams was a predictive factor for MGD with a sensitivity of 72% and a specificity of 66%. CONCLUSIONS: Only the weight of the resected parathyroid adenoma was meaningful in predicting MGD. A cut-off value of 0.418 g can differentiate SGD from MGD.

Predictive Factors for Bilateral Disease in Papillary Microcarcinoma: A Retrospective Cohort Study.

Background: Based on risk stratification, the therapeutic options in papillary microcarcinoma (PTMC) can be active surveillance or surgery. Multifocal tumor occurrence can be decisive in determining the treatment strategy. The objective of this study was to identify risk factors for bilateral tumor occurrence in PTMC to enable individual therapy planning. Methods: A total of 545 PTMC patients who underwent thyroidectomy from 2008 to 2020 were retrieved. Univariate and multivariate analyses were performed to evaluate risk factors for bilateral PTMC. Results: 25.1% (n = 137) of all patients had multifocal PTMC, and 13.2% (n = 72) bilateral PTMC, respectively. In contrast to the maximum tumor size, the total tumor size significantly influenced a bilateral tumor manifestation (median total tumor size 5 mm versus 8.5 mm for bilateral PTMC, p < 0.001). A cut-off level for the total tumor size of >10 mm resulted in a sensitivity and specificity of 29.2% and 94.7%, respectively, in predicting a bilateral tumor manifestation, AUC 0.680 (95% CI, 0.611−0.748, p < 0.001). A cut-off of >4 tumors showed a sensitivity of 99.4% and a specificity of 97.5%, AUC 0.897 (95% CI, 0.870−0.924, p < 0.001) in predicting bilaterality. Conclusion: We could demonstrate for the first time that a total tumor size of >10 mm and more than four tumors significantly increased the risk of bilateral PTMC tumor involvement. These findings enable a risk-adjusted patient treatment.

Accuracy of Parathyroid Adenoma Localization by Preoperative Ultrasound and Sestamibi in 1089 Patients with Primary Hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism (pHPT) is well treatable surgically. Sonography (US) and sestamibi scintigraphy (MIBI) are used routinely, but it is unclear how valuable they are in determining Parathyroid glands' different locations. This study aimed to evaluate the prognostic value of US and MIBI in relation to the different localization of parathyroid adenomas in one of the largest study populations analyzed to date. METHODS: 1089 patients with pHPT who had treatment in one tertiary referral center between 2007 and 2016 were analyzed. Preoperative US and MIBI reports were compared with the parathyroid adenoma's intraoperative localization. All parathyroid glands were confirmed by histological diagnosis. RESULTS: No gland was detectable in 22.5% and 27.7% of all patients, by US or by MIBI, respectively. In relation to the different adenoma locations, the sensitivity of US ranged from 21.3% (upper right) to 68.9% (lower left) and of MIBI ranged from 23.5% (upper right) to 72% (lower left). The specificity for US ranged from 85% (lower right) to 99.2% (upper right) and for MIBI ranged from 86.1% (lower right) to 99.1% (upper right. Positive predictive values for all gland sites were 54% and 59% for MIBI and US, respectively. The value increased for side-only prediction to 73% and 78%, respectively. Neither the parathyroid hormone level nor the calcium value level influenced the sensitivity or specificity of the two test methods. CONCLUSIONS: The validity of preoperative US and MIBI depends crucially on the specific localization of adenomas. This should be considered when planning the extent of parathyroid surgery.

Recurrent laryngeal nerve paresis in benign thyroid surgery with and without intraoperative nerve monitoring.

BACKGROUND: Recurrent laryngeal nerve (RLN) paresis is a rare but serious complication in thyroid surgery. Intermittent intraoperative nerve monitoring (IONM) was thought to prevent paresis of the RLN, but until today data are not conclusive. Our objective was to confirm the hypothesis that IONM can reduce paresis of RLN compared to nerve visualization alone. Therefore, we examined one of the largest cohorts ever evaluated of a tertiary referral center for endocrine surgery undergoing thyroid surgery for benign thyroid disease. METHODS: Overall, 2097 patients who underwent thyroid surgery for benign thyroid disease in 2016 and 2017 were evaluated. RLN was identified by IONM or visualization only. Preoperative and postoperative laryngoscopic examination was used to evaluate RLN paresis. Patients' characteristics and perioperative data were extracted retrospectively. RESULTS: Overall, 1963 patients (2720 nerves at risk [NAR]) were included in this study: 378 surgeries with IONM (560 NAR) and 1585 without IONM (2160 NAR). Transient and permanent RLN pareses were found in 13 (3.4%; NAR=2.3%) and one (0.3%; NAR=0.2%) nerve treated with IONM vs. 37 (2.3%; NAR=1.7%) and five (0.3%; NAR=0.2%) nerves without IONM (P=0.507; NAR P=0.654), respectively. CONCLUSIONS: Using intermittent IONM, our retrospective study could not demonstrate a significant decrease of RLN pareses in patients undergoing thyroid surgery for benign thyroid disease. This is probably explained by the very low overall number of RLN pareses in our department. Nevertheless, because of patients' safety to avoid any bilateral RLN pareses, we recommend IONM in bilateral resections.

Cystic lymph node metastasis of papillary thyroid cancer: clinical facts.

BACKGROUND: The therapy planning for cystic cervical lesions is dizzying. Although it is mostly a benign disease, it can also be a cystic lymph node metastasis with the origin of papillary thyroid cancer (PTC). METHODS: Included were all patients with histological confirmed PTC, who underwent a thyroid resection from January 2012 to December 2017 (N.=680). Analyzed were demographic data including family history and radiation exposure, preoperative workup including thyroid ultrasound and laboratory test of the TSH value complimented by fine-needle aspiration in case of suspected malignancy, and clinicopathologic features. This study aimed to specify preoperative findings and patients' clinical presentation with cystic lymph node metastasis of PTC. RESULTS: In 0.7% (5/680) of all patients with PTC a cystic cervical lesion was histologically confirmed as cystic lymph node metastasis. Preoperatively, only two of these patients were suspected of lymph node metastasis with unknown origin. In three patients, the resected cystic lymph node metastases were the only lymphatic metastasis. Interestingly 80% (4/5) of the patients suffered from papillary microcarcinoma (MPTC). CONCLUSIONS: Cervical cystic lesions may be challenging in diagnostics and therapy. Although the recommended thyroid ultrasound may detect no pathological findings, a papillary microcarcinoma can be the primary tumor.

Preoperative Potassium Iodide Treatment in Patients Undergoing Thyroidectomy for Graves' Disease-Perspective of a European High-Volume Center.

BACKGROUND: Potassium iodide (KI) treatment affects the vascularity of the thyroid gland and therefore may improve intraoperative visualization of essential structures. However, clear evidence for its usage is lacking, and its implementation in patients suffering from Graves' disease is becoming rare. The objective of this retrospective study was to assess the impact of KI treatment on the intraoperative course and the outcome of patients undergoing thyroidectomy for Graves' diseases. METHODS: The study included 442 patients: 125 patients (28.3%) who received a preoperative treatment with KI ("Group KI") and 317 patients (71.7%) without a KI therapy ("Group No-KI"). Indication for KI treatment was a thyroid bruit (82.5%), as well as hyperthyroidism refractive to medical treatment with antithyroid drugs (17.4%). RESULTS: All patients underwent total thyroidectomy. Permanent vocal cord paresis and permanent hypoparathyroidism were similar in both groups. KI treatment was associated with a significantly longer operative time (142 vs. 128 min, p < 0.001) and a significant higher weight of the thyroid gland. KI treatment did not impact duration of hospital stay or occurrence of secondary hemorrhage. CONCLUSIONS: The complication rate of this study population with clinically severe GD was very low-which may be caused by pre-treatment of patients. The complementary option of a potassium iodide treatment before surgery remains a possibility and should be implemented individually.

Papillary Thyroid Cancer and Coexisting Autoimmune Thyroiditis.

Histological findings often display an association between papillary thyroid carcinomas (PTC) and autoimmune thyroiditis (AIT) and so differ significantly from follicular thyroid carcinomas (FTC). The aim of this interdisciplinary, retrospective study was to evaluate the association of AIT in patients with PTC and FTC and a control group of benign nodular goiters. One hundred thyroidectomies with histologically confirmed differentiated thyroid carcinomas, 67 with PTC and 33 with FTC, were submitted for examination. The two control groups consisted of 60 patients with euthyroid nodular goiter, displaying no signs for malignancy (no surgery) and 100 patients (second control group) with surgery of a benign nodular goiter. Controls were collected to obtain data about the incidence of significantly increased TPOAbs in the first group and of lymphocytic infiltrates (LI) in the second group. High TPOAbs were found in 35% (23/67) of patients with PTC. LI were detected by histology in 48% (32/67) of PTC. Ten patients (10/32) of this group showed the clinical and histological manifestation of a classic AIT with diffuse dense LI as well as diffuse hypoechogeneity in ultrasonography. In 7/32 cases, the histological report described focal dense LI (fAIT) and in 15/32 cases scant scattered LI. AIT and fAIT, together 25% of all PTC (17/67), showed germinal centers and can therefore be characterized as chronic autoimmune thyroiditis. In this group, high TPOAb could be detected in 94% (16/17). Scan scattered LI without germinal centers (15/32) do not represent a fAIT, although TPOAb are high in 47% (7/15). The younger age group (<45 years) showed significantly more often high TPOAbs (p<0.023) in comparison with the age-group older than 60 years. In contrast to PTC, only 4/33 (12%) patients with FTC had high TPOAb levels. We conclude that in contrast to benign euthyroid goiters and to FTC, different degrees of LI are often associated with high TPOAb levels and seem to be significantly increased in PTC, particularly prominent in younger age. There is a high coincidence between LI and high TPOAb levels. In the presence of hypoechoic thyroid nodule, signs of thyroid autoimmunity such as the presence of high TPOAbs, lymphocytic infiltration in cytology, and/or characteristic ultrasonic features, are arguments that might favor the decision for surgery if a cytologically indeterminate thyroid nodule is found and focal autonomy is excluded by szintiscan.

German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors.

INTRODUCTION: Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable ("low risk") papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages. METHODS: The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization. RESULTS: The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases. CONCLUSION: These evidence-based recommendations for surgical therapy reflect various "treatment corridors" that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.

German Association of Endocrine Surgeons practice guidelines for the surgical treatment of benign thyroid disease.

INTRODUCTION: Benign thyroid disorders are among the most common diseases in Germany, affecting around 15 million people and leading to more than 100,000 thyroid surgeries per year. Since the first German guidelines for the surgical treatment of benign goiter were published in 1998, abundant new information has become available, significantly shifting surgical strategy towards more radical interventions. Additionally, minimally invasive techniques have been developed and gained wide usage. These circumstances demanded a revision of the guidelines. METHODS: Based on a review of relevant recent guidelines from other groups and additional literature, unpublished data, and clinical experience, the German Association of Endocrine Surgeons formulated new recommendations on the surgical treatment of benign thyroid diseases. These guidelines were developed through a formal expert consensus process and in collaboration with the German societies of Nuclear Medicine, Endocrinology, Pathology, and Phoniatrics & Pedaudiology as well as two patient organizations. Consensus was achieved through several moderated conferences of surgical experts and representatives of the collaborating medical societies and patient organizations. RESULTS: The revised guidelines for the surgical treatment of benign thyroid diseases include recommendations regarding the preoperative assessment necessary to determine when surgery is indicated. Recommendations regarding the extent of resection, surgical techniques, and perioperative management are also given in order to optimize patient outcomes. CONCLUSIONS: Evidence-based recommendations for the surgical treatment of benign thyroid diseases have been created to aid the surgeon and to support optimal patient care, based on current knowledge. These recommendations comply with the Association of the Scientific Medical Societies in Germany requirements for S2k guidelines.