CT features of parathyroid carcinomas: comparison with benign parathyroid lesions.

PURPOSE: To describe CT features of parathyroid carcinomas (PCs) by comparison with benign parathyroid lesions (BPs). METHODS: This retrospective study comprised 82 patients with 76 BPs (62 adenomas and 14 hyperplastic lesions) and 6 PCs. CT features (size, short-to-long axis ratio, shape, peritumoral infiltration, homogeneity, calcification, attenuation values on unenhanced CT, and contrast enhancement during arterial and venous phases) were compared between PCs and BPs. The diagnostic performance of CT features for diagnosing PCs was calculated for these individual parameters. RESULTS: Short-to-long axis ratio was significantly larger in PCs (0.7 ± 0.1) than in BPs (0.5 ± 0.1, p = 0.004). Irregular shape (33%), the presence of peritumoral infiltration (50%), and calcification (33%) were significantly more common in PCs than BPs. The contrast enhancement value was significantly lower in PCs than BPs during arterial (p = 0.004) and venous phases (p = 0.044). The 100% sensitivity criterion for the short-to-long axis ratio (≥ 0.53), enhancement during arterial phase (≤ 56.6HU), and venous phase (≤ 59.5HU) yielded accuracies (62.1%, 71.9%, and 75.4%, respectively). Irregular shape, peritumoral infiltration, and calcification showed high specificity (98.7%) and accuracy (93.9%, 95.1%, and 93.9%, respectively). CONCLUSIONS: CT features of high short-to-long axis ratio, irregular shape, the presence of peritumoral infiltration and calcification, and low contrast enhancement may aid in distinguishing PCs from BPs.

Intraoperative Identification of the Parathyroid Gland with a Fluorescence Detection System.

BACKGROUND: Intraoperative identification of the difficult-to-spot parathyroid gland is critical during surgery for thyroid and parathyroid disease. Recently, intrinsic fluorescence of the parathyroid gland was identified, and a new method was developed for intraoperative detection of the parathyroid with an original fluorescent detection apparatus. Here, we describe a method for intraoperative detection of the parathyroid using a ready-made photodynamic eye (PDE) system without any fluorescent dye or contrast agents. METHODS: Seventeen patients who underwent surgical treatment for thyroid or parathyroid disease at Kagoshima University Hospital were enrolled in this study. Intrinsic fluorescence of various tissues was detected with the PDE system. Intraoperative in vivo and ex vivo intrinsic fluorescence of the parathyroid, thyroid, lymph nodes and fat tissues was measured and analyzed. RESULTS: The parathyroid gland had a significantly higher fluorescence intensity than the other tissues, including the thyroid glands, lymph nodes and fat tissues, and we could identify them during surgery using the fluorescence-guided method. Our method could be applicable for two intraoperative clinical procedures: ex vivo tissue identification of parathyroid tissue and in vivo identification of the location of the parathyroid gland, including ectopic glands. CONCLUSION: The PDE system may be an easy and highly feasible method to identify the parathyroid gland during surgery.

Bidirectional Approach of Video-Assisted Neck Surgery (BAVANS): Endoscopic complete central node dissection with craniocaudal view for treatment of thyroid cancer.

INTRODUCTION: Endoscopic thyroidectomy is a well-established surgical technique that is mainly performed for benign thyroid disease. We considered that endoscopic surgery could also be widely indicated for the treatment of thyroid cancer. We herein describe our new bidirectional approach of video-assisted neck surgery (BAVANS) for complete central node dissection in endoscopic thyroid cancer surgery. METHODS: BAVANS involves two different directional pathways to the cervical lesion. Before lymph node dissection, we perform endoscopic thyroidectomy via a conventional gasless precordial or axillary approach. After thyroidectomy, the surgeon repositions by the head of the patient and inserts three ports in front of the upper neck lesion in the submandibular area to approach the paratracheal lesion from an overhead-to-caudal direction. RESULTS: BAVANS allows for an excellent craniocaudal view and easy access to the peritracheal lymph nodes. Sixteen patients with papillary thyroid cancer underwent BAVANS and progressed satisfactorily after surgery. Of those patients, eight underwent total or near total thyroidectomy, and five patients underwent bilateral central node dissection. The average number of retrieved lymph nodes with unilateral central node dissection was nine, which was higher than that achieved with conventional open surgery. All patients began oral intake within 5 h after surgery. Postoperative Horner syndrome occurred in one patient. No other complications were noted. CONCLUSIONS: BAVANS is a very effective surgical procedure that many endoscopic surgeons can perform safely and easily. It has both a cosmetic advantage and excellent curability in endoscopic thyroid cancer surgery.

Clinical Significance of the Histoculture Drug Response Assay in Breast Cancer.

BACKGROUND/AIM: Despite the fact that breast cancer patients are generally administered systemic chemotherapy after surgical treatment, predictive factors that allow optimization of chemotherapy are needed. The histoculture drug response assay (HDRA) is a clinically practical in vitro drug-response assay for identifying optimal anticancer agents. PATIENTS AND METHODS: Thirty-eight primary breast cancer patients who underwent surgical treatment without receiving systemic neoadjuvant therapy were analyzed. We retrospectively examined the relationships between clinicopathological factors and the HDRA results of 5 anticancer agents (mitomycin C (MMC), 5-fluorouracil (5-FU), doxorubicin hydrochloride (ADM), cisplatin (CDDP) and paclitaxel (PTX)). RESULTS: The relationships between the inhibition rates of anticancer drugs and clinicopathological factors were not significant, except for nuclear grade and venous invasion with the inhibition rate of 5-FU. We also established the threshold inhibition rate for PTX. The paclitaxel inhibition rate was significantly associated with disease-free survival (DFS). CONCLUSION: HDRA results were independent from the clinicopathological factors of breast cancer patients demonstrating that individualized treatment is needed.

Therapeutic mammoplasty combining partial mastectomy with nipple-areola grafting for patients with early breast cancer: a case series.

PURPOSE: Therapeutic mammoplasty (TM) for breast cancer is a widely practiced oncoplastic technique. Intraductal spread towards the nipple or the location of the cancerous lesion on the central breast may become a contraindication for breast-conserving surgery. We herein report the results of TM in such cases. METHODS: Six patients underwent TM that combined partial mastectomy with free nipple-areola (NA) grafting. The nipple was removed together with the cancerous lesions, and the areola was preserved for NA reconstruction. The tumors were located in the lower quadrant (n = 1), the central area (n = 1), the upper-outer area (n = 2), and the upper-inner area (n = 2). The types of mammoplasty that were performed included: amputation (n = 1), inverted T mammoplasty (n = 3), and L mammoplasty (n = 2). With the exception of one patient, all patients underwent inverted T mammoplasty on the contralateral breast in order to achieve symmetry. RESULTS: The total surgical and plastic periods ranged from 155 to 235 min (mean 207 min) and 100 to 150 min (mean 121 min), respectively. Oncological safety and excellent cosmetic results were achieved. CONCLUSIONS: TM combining partial mastectomy with NA grafting was successfully performed in patients with early-stage cancer in all quadrant areas.

The clinical usefulness of the intraoperative detection of sentinel lymph node metastases by a rapid RT-PCR system in patients with gastric cancer.

BACKGROUND: The incidence of pathological lymph node metastases in patients with gastric cancer is 5% to 10%, which means that approximately 90% of patients with gastric cancer may undergo unnecessary lymphadenectomy. The precise intraoperative diagnosis of sentinel lymph node (SN) metastases is essential. The purpose of the current study was to verify the usefulness of a rapid reverse transcriptase-polymerase chain reaction (RT-PCR) system compared with hematoxylin and eosin staining for such diagnoses. METHODS: A total of 113 patients with clinical T1-T2 (cT1-T2) gastric cancer, including 73 patients with cT1cN0 disease with a tumor diameter <4 cm, were enrolled in the current study. SNs were identified by a radioisotope method. Carcinoembryonic antigen and cytokeratin 19 were used as markers for RT-PCR and the cutoff values were set using 1701 lymph nodes harvested from 157 patients with gastric cancer. RESULTS: SNs were detected in all 113 patients. Sensitivity and accuracy for detection by paraffin section were both 100% in patients with cT1 disease and were 60% and 90%, respectively, in patients with cT2 disease. The sensitivity of RT-PCR for the detection of pathological SN metastases was 92.3%. Furthermore, 11 patients had SN metastases detected only by RT-PCR, and these patients had frequent lymphatic invasion. Hematoxylin and eosin staining detected SN metastases in 6 of 73 patients with cT1cN0 gastric cancer; RT-PCR and frozen section detected SN metastases in 6 and 4 of these patients, respectively. Accordingly, the sensitivity of RT-PCR and frozen section for the detection of those pathological SN metastases were 100% and 66.6%, respectively. CONCLUSIONS: The rapid RT-PCR system appears to have clinical usefulness for the intraoperative detection of SN metastases in patients with gastric cancer.

Clinical Significance of Circulating Tumor Cells in Peripheral Blood of Patients with Esophageal Squamous Cell Carcinoma.

BACKGROUND: Esophageal squamous cell carcinoma is an aggressive gastrointestinal tract cancer. To date, the presence of circulating tumor cells (CTC) has been reported as a prognostic factor in peripheral blood from patients with gastrointestinal cancers. METHODS: The CellSearch system was used to isolate and enumerate CTCs. A total of 90 patients with esophageal squamous cell carcinoma who received chemotherapy or chemoradiotherapy were enrolled. Peripheral blood specimens were collected before and after treatments. RESULTS: At baseline analysis, CTCs were detected in 25 patients (27.8 %). Overall survival was significantly shorter in patients with than without CTCs. Follow-up blood specimens were obtained from 71 patients. Partial response, stable disease, and progressive disease after treatment were seen in 32, 12, and 27 patients, respectively. CTC positivity after treatment in the progressive disease group (40.7 %) was significantly higher than that of the partial response group (6.3 %). Patients with a change in CTC status from positive to negative had a good prognosis as well as patients without baseline CTCs. CONCLUSIONS: Evaluation of CTCs may be a promising indicator for predicting tumor prognosis and the clinical efficacy of chemotherapy or chemoradiation therapy in patients with esophageal squamous cell carcinoma.

Histological findings of an autologous dermal fat graft implanted onto the pectoralis major muscle of a rat model.

BACKGROUND: The aim of this study was to investigate the maintenance of volume as a spacer by comparing vascular supply and apoptosis in an implanted autologous-free dermal fat graft (FDFG) and free fat graft (FFG). An autologous FDFG is a material used in plastic surgery and oncoplastic breast surgery that is ideal for immediate volume replacement after partial mastectomy because of its easy availability and minimal invasion of the donor site; however, immunohistochemical findings and survival procedures have not yet been reported. METHODS: An experimental protocol using a unique animal model was designed for the present study. The expression of vascular endothelial growth factor (VEGF) was measured in FDFGs and FFGs implanted onto the pectoral major muscle of Wistar rats. Thirty Wistar rats were divided into two groups and postoperatively 1, 2, 4, 8, and 16 weeks (POW1, 2, 4, 8, 16). Six samples from three rats in each group were used as control samples (POW0). RESULTS: The thickness of the implanted FDFG was not significantly different from the control sample at POW1, 2, 4, 8, and 16 between FDFG and FFG group; however, the thickness at POW8 and 16 was significantly lesser in the FFG group than in the control samples. The average proportion of fatty tissue to whole tissue ranged from 34.2 to 48.6 % in the FDFG group and from 57.2 to 76.7 % in the FFG group during the observation period; however, there was no significant difference in the proportion of fatty tissue between these two groups. There were no significant differences between the average number of VEGF-positive cells in the FDFG group and the FFG group at POW1, 2, 4, 8, and 16. The average number of TUNEL-positive cells in the early period at POW1 was significantly lower in the FDFG group than in the FFG group. CONCLUSIONS: This rat model was useful for investigating the mechanisms of angiogenesis, apoptosis, structure maintenance, and fibromatous changes. From the present experimental study, we believe that FDFG is one of the most convenient materials currently available to repair small defects at the time of BCS even in the clinical field.

Impaired wound healing and expansion of a large ulcer after bevacizumab with paclitaxel for skin metastases from breast cancer: report of a case.

A 48-year-old Japanese woman was found to have local recurrence of breast cancer in the chest wall following neoadjuvant chemotherapy, total mastectomy with axillary lymphadenectomy, postoperative radiation therapy to the chest wall, and adjuvant systemic therapy using trastuzumab. As a third line of treatment after recurrence, bevacizumab with paclitaxel was initiated for several metastatic lesions on the skin of the chest wall, left internal costal lymph nodes, and right axillary lymph nodes. The wound on the chest wall continued to expand in diameter and depth after the third course of bevacizumab with paclitaxel until the rib was exposed. After stopping the bevacizumab, granulation tissue expanded and by 3 months, had covered the bottom of the ulcer. The patient died soon thereafter, despite systemic chemotherapy with eribulin; however, there was no further bleeding from the ulcer on the chest wall or the exposed ribs.

Computed tomography Hounsfield units can predict breast cancer metastasis to axillary lymph nodes.

BACKGROUND: Axillary lymph node (ALN) status is an important prognostic factor for breast cancer. We retrospectively used contrast-enhanced computed tomography (CE-CT) to evaluate the presence of ALN, metastasis based on size, shape, and contrasting effects. METHODS: Of 131 consecutive patients who underwent CE-CT followed by surgery for breast cancer between 2005 and 2012 in our institution, 49 were histologically diagnosed with lymph node metastasis. Maximum Hounsfield units (HU) and mean HU were measured in non-contrasting CT (NC-CT) and CE-CT of ALNs. RESULTS: Of 12 examined measurements, we found significant differences between negative and metastatic ALNs in mean and maximum NC-CT HU, and mean and maximum CE-CT HU (P < 0.05). We used a receiver operating curve, to determine cut-off values of four items in which significant differences were observed. The highest accuracy rate was noted for the cut-off value of 54 as maximum NC-CT HU for which sensitivity, specificity, and accuracy rate were 79.6%, 80.5% and 80.2%, respectively. CONCLUSIONS: CT HU of a patient with breast cancer are absolute values that offer objective disease management data that are not influenced by the screener's ability.

Oncoplastic breast surgery for centrally located breast cancer: a case series.

Oncoplastic breast surgery (OBS), which combines the concepts of oncologic and plastic surgery, is becoming more common worldwide. We herein report the results of OBS in Japanese patients with centrally located breast cancer (CLBC) and Paget's disease. We performed OBS combining partial mastectomy and immediate volume replacement on patients with non-ptotic and/or small breasts, and volume reduction surgery for patients with ptotic breasts, as reported in Western countries. Japanese encounters are described in this report as a case series.

Oncoplastic breast surgery combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap for Paget's disease.

Oncoplastic breast surgery (OBS), which combines the concepts of oncologic and plastic surgery, is becoming more common worldwide. We herein report the results of OBS in Japanese patients with Paget's disease. We performed OBS combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap in two patients. In these two patients, who were diagnosed as having Paget's disease with a restricted intraductal component in the central area of their non-ptotic breast, we performed oncoplastic surgery combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap. Neither of the two patients received contralateral surgery to produce symmetrical breasts. The observation period ranged from 6 to 12 months, and the bilateral breast volumes and inframammary lines were symmetric. OBS combining partial mastectomy with immediate breast reshaping using a keyhole-shaped skin glandular flap was successfully performed in two patients with Paget's disease.

Oncoplastic surgery combining partial mastectomy and immediate volume replacement using a thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis.

PURPOSE: The treatment of early breast cancer using breast-conserving therapy commonly ensures local control and acceptable cosmetic results. We herein report a useful technique, including the use of a thoracodorsal adipofascial cutaneous flap for reconstructing defects in the outer quadrant area after partial mastectomy, which achieved excellent results. METHODS: We performed partial mastectomy followed by immediate volume replacement using a modified thoracodorsal adipofascial cutaneous flap with a crescent-shaped dermis in ten patients. RESULTS: The modified oncoplastic technique was performed without any complications in all patients. Sufficient blood flow to the cutaneous flap with the crescent-shaped dermis was visualized in two patients during the operation after the injection of indocyanine green. The oncological and cosmetic results were excellent to good in these patients. CONCLUSIONS: Oncoplastic surgery using a modified thoracodorsal adipofascial flap with a crescent-shaped dermis was successfully performed in patients with early cancer lesions in the outer quadrant, and the cosmetic results obtained were excellent.

Oncoplastic surgery in a Japanese patient with breast cancer in the lower inner quadrant area: partial mastectomy using horizontal reduction mammoplasty.

We report the results of oncoplastic surgery in a Japanese patient with early breast cancer. Her breasts were ptotic, and her lesion was considered to be suitable for breast-conserving surgery. Oncoplastic surgery involving partial resection of the gland and a horizontal-type mammoplasty was performed. The technique was easy to perform, and the cosmetic outcome was excellent.

Clinical significance of circulating tumor cells in peripheral blood from patients with gastric cancer.

BACKGROUND: The authors hypothesized that circulating tumor cells (CTCs) in patients with gastric cancer are associated with prognosis and disease recurrence. In this study, they evaluated CTCs in gastric cancer and clarified the clinical impact of CTCs. METHODS: In total, 265 consecutive patients with gastric cancer were enrolled. Fourteen patients were excluded from the analysis, including 12 patients who another cancer and 2 patients who refused the treatment. The remaining 251 patients were divided into 2 groups: 148 patients who underwent gastrectomy (the resection group) and 103 patients who did not undergo gastrectomy (the nonresectable group). Peripheral blood samples were collected before gastrectomy or chemotherapy. A proprietary test for capturing, identifying, and counting CTCs in blood was used for the isolation and enumeration of CTCs. RESULTS: CTCs were detected in 16 patients (10.8%) from the resection group and in 62 patients (60.2%) from the nonresectable group. The overall survival rate for the entire cohort was significantly lower in patients with CTCs than in those without CTCs (P < .0001). In the resection group, relapse-free and overall survival in patients with CTCs was significantly lower than in patients without CTCs (P < .0001). It was noteworthy that the expression of CTCs was an independent factor for determining the overall survival of patients with gastric cancer in multivariate analysis (P = .024). In the nonresectable group, the overall survival rate was significantly lower in patients with CTCs than in those without CTCs (P = .0044). CONCLUSIONS: The evaluation of CTCs in peripheral blood may be a useful tool for predicting tumor progression, prognosis, and the effect of chemotherapy in patients with gastric cancer.

Feasibility of sentinel node navigation surgery after noncurative endoscopic resection for early gastric cancer.

BACKGROUND AND AIM: Recently, the use of additional surgery after noncurative endoscopic resection has gradually increased due to the rapid spread of endoscopic treatments in selected patients with early gastric cancer. Sentinel node navigation surgery (SNNS) has also been recognized as a minimally invasive surgery with personalized lymphadenectomy in early gastric cancer. Here, we assessed the feasibility of SNNS after noncurative endoscopic resection for early gastric cancer. METHODS: Sixteen patients with early gastric cancer, in whom additional surgery had been indicated due to noncurative endoscopic resection, were enrolled. They underwent a gastrectomy with standard lymphadenectomy. One day before surgery, (99m) technetium-tin colloid was endoscopically injected into the submucosa around the tumor. After surgery, the uptake of radioisotope in dissected lymph nodes was measured using Navigator GPS. Then, all dissected lymph nodes were investigated by hematoxylin-eosin staining and immunohistochemistry using an antihuman cytokeratin monoclonal antibody. RESULTS: Hematoxylin-eosin staining demonstrated lymph node metastasis in two (12.5%) of 16 patients and in three (0.8%) of 382 nodes. However, immunohistochemistry showed that none of the patients had lymph node micrometastasis. Sentinel nodes (SNs) were identified in all patients. The mean number of SNs was 3.1 (range, 1-6). Among two patients with lymph node metastasis, the SNs, at least, contained positive nodes. Accordingly, the false-negative and accuracy rates were 0% and 100%, respectively. CONCLUSION: Our results indicate that SNNS may have potential as a further minimally invasive surgery in early gastric cancer patients after noncurative endoscopic resection.

Assessment of sentinel node concept in esophageal cancer based on lymph node micrometastasis.

PURPOSE: The clinical significance of lymph node micrometastasis remains unclear in patients with esophageal cancer. Therefore, accurate assessment of lymph node status including micrometastasis is important when performing sentinel node (SN) navigation surgery. The purpose of the present study was to investigate the adequacy of SN concept based on lymph node micrometastasis determined by immunohistochemistry (IHC) and reverse transcription-polymerase chain reaction (RT-PCR) in patients with esophageal cancer. METHODS: A total of 57 patients with esophageal cancer who were preoperatively diagnosed as having T1-T2 (cT1-T2) and N0 (cN0) were enrolled. They underwent standard esophagectomy with lymph node dissection. One day before surgery, a total of 3 mCi of 99mTechnetium-tin colloid was endoscopically injected into the submucosa around the tumor. During the operation, radioisotope uptake in the lymph nodes was measured using Navigator GPS. All dissected lymph nodes were investigated by RT-PCR using the double marker of CEA and SCC, hematoxylin-eosin (HE) staining, and IHC. RESULTS: Node-positive incidence identified by HE and IHC was 12.3% (7/57) and 19.3% (11/57), respectively. RT-PCR demonstrated micrometastasis in four of 46 patients without nodal metastasis determined by HE staining and IHC. No non-SN metastases were found in 42 patients without micrometastasis identified by IHC and RT-PCR of SN. Accuracy and false negative rates were 100% (57/57) and 0% (0/42), respectively. CONCLUSIONS: SN concept might be acceptable in patients with cT1-T2 and cN0 esophageal cancer, even in the presence of micrometastasis identified by IHC and RT-PCR.

Oncoplastic breast surgery combining periareolar mammoplasty with volume displacement using a crescent-shaped cutaneous flap for early breast cancer in the upper quadrant.

Oncoplastic breast surgery (OBS), which combines the concepts of oncological and plastic surgery, is becoming more common, especially in Western countries; however, only a few reports have been published in Japan. We herein report the results of OBS for Japanese patients with early breast cancer in the upper quadrant. We performed oncoplastic surgery combining partial mastectomy using a periareolar incision with immediate breast reshaping using a crescent-shaped cutaneous flap in three patients with a past history of breast-feeding, ptotic breasts and lesions that were suitable for breast conserving surgery. The lesions were located in the upper quadrant and were 5, 6 and 10 cm from the nipple, respectively. The total length of the operations ranged between 86 and 192 min, with the mean being 164 min. Two patients underwent contralateral surgery to produce symmetrical breasts and one did not. The plastic period after receiving pathological results intraoperatively ranged between 47 and 120 min, with the mean period being 82 min. The observation period ranged between 6 and 12 months, and the cosmetic results were excellent in all three cases. OBS combining partial mastectomy using a periareolar incision with immediate breast reshaping using a crescent-shaped cutaneous flap was successfully performed in patients with early cancer in the upper quadrant.

Immediate reconstruction using a modified inframammary adipofascial flap after partial mastectomy.

Breast conservative therapy (BCT) as treatment for early breast cancer usually ensures local control and acceptable cosmetic results. We describe a new technique of using an inframammary adipofascial flap to reconstruct defects caused by lower-pole partial mastectomy, which achieved excellent results (Kijima et al. in Am J Surg 193:789-91 (1); Sakai et al. in Ann Plast Surg 29(2):173-7, 2; Ogawa Am J Surg 193:514-8, 3). We developed this procedure as an oncoplastic technique for a Japanese woman with a similar defect without ptosis. After partial mastectomy, the superior half of the flap is harvested via an initial incision along the inframammary line, and the inferior half is harvested via an additional incision along the caudal edge of the flap, to produce a crescent of de-epithelialized skin. A tongue-shaped flap containing the crescent of de-epithelialized skin, subcutaneous fat, and the fascia of the vertical rectus abdominis muscle is then rotated upwards, gathered, and inserted into the breast defect.

Trans-Oral Video-Assisted Neck Surgery (TOVANS). A new transoral technique of endoscopic thyroidectomy with gasless premandible approach.

BACKGROUND: Endoscopic thyroidectomy is a well-established surgical technique. We have been utilizing precordial video-assisted neck surgery (VANS) with a gasless anterior neck skin lifting method. Recently, natural orifice transluminal endoscopic surgery (NOTES) has generated excitement among surgeons as potentially scar-free surgery. We developed an innovative gasless transoral technique for endoscopic thyroidectomy that incorporated the concept of NOTES in a VANS-technique. METHODS: Incision was made at the vestibulum under the inferior lip. From the vestibulum to the anterior cervical region, a subplatysmal tunnel in front of the mandible was created and cervical skin was lifted by Kirschner wires and a mechanical retracting system. This method without CO2 insufflation created an effective working space and provided an excellent cranio-caudal view so that we could perform thyroidectomy and central node dissection safely. RESULTS: Beginning with our first clinical application of TOVANS in September 2009, we have performed eight such procedures. Three of the eight patients had papillary microcarcinoma and received central node dissection after thyroidectomy. All patients began oral intake 1 day after surgery. The sensory disorder around the chin persisted more than 6 months after surgery in all patients. Recurrent laryngeal nerve palsy revealed in one patient. Nobody had mental nerve palsy, and no infection developed with use of preventive antibacterial tablets for 3 days. CONCLUSIONS: We developed a new method for gasless transoral endoscopic thyroidectomy with a premandible approach and anterior neck-skin lifting. TOVANS makes possible complete endoscopic radical lymphadenectomy for papillary thyroid cancer. We believe that this method is innovative and progressive and has not only a cosmetic advantage but also provides easy access to the central node compartment for dissection in endoscopic thyroid cancer surgery.