Preoperative Evaluation of Thyroid Cancer: A Review of Current Best Practices.

OBJECTIVE: The incidence of thyroid cancer has significantly increased in recent decades. Although most thyroid cancers are small and carry an excellent prognosis, a subset of patients present with advanced thyroid cancer, which is associated with increased rates of morbidity and mortality. The management of thyroid cancer requires a thoughtful individualized approach to optimize oncologic outcomes and minimize morbidity associated with treatment. Because endocrinologists usually play a key role in the initial diagnosis and evaluation of thyroid cancers, a thorough understanding of the critical components of the preoperative evaluation facilitates the development of a timely and comprehensive management plan. The following review outlines considerations in the preoperative evaluation of patients with thyroid cancer. METHODS: A clinical review based on current literature was generated by a multidisciplinary author panel. RESULTS: A review of considerations in the preoperative evaluation of thyroid cancer is provided. The topic areas include initial clinical evaluation, imaging modalities, cytologic evaluation, and the evolving role of mutational testing. Special considerations in the management of advanced thyroid cancer are discussed. CONCLUSION: Thorough and thoughtful preoperative evaluation is critical for formulating an appropriate treatment strategy in the management of thyroid cancer.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement.

BACKGROUND: This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking. METHODS: An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements. CONCLUSIONS: This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

Outcomes of incidentally discovered thyroid nodules referred to a high-volume head and neck surgeon.

BACKGROUND: Incidental thyroid nodules are commonly found by radiological studies done for other indications. The yearly incidence of thyroid cancer is increasing, in part because of detection of nonpalpable nodules on imaging performed for unrelated issues. METHODS: All new patients referred to a high-volume thyroid surgeon for thyroid nodules were reviewed between February 2009 and January 2011. Data regarding patient demographics, risk factors, referring physician, radiologic findings, fine-needle aspiration (FNA) results, and management were reviewed. RESULTS: One hundred thirty-three of 729 patients (18.2%) had a thyroid nodule or nodules incidentally found on ultrasound, MRI, CT, nuclear imaging, or chest x-ray. Fifty-five patients (41.4%) were managed surgically, with 35 (63.6%) of those having thyroid cancer on final surgical pathology. CONCLUSION: Based on radiologic findings, risk factors, and FNA results, many incidental thyroid nodules can be observed. Incidental thyroid nodules should be evaluated in the same fashion as a palpable thyroid nodule.

Metastatic papillary thyroid cancer with lateral neck disease: pattern of spread by level.

BACKGROUND: Currently, there is no clear consensus on the extent of this lateral neck dissection required in papillary thyroid cancer (PTC) with lateral neck metastasis. The purpose of this study was to review our experience with metastatic PTC, and identify the pattern of lymphatic spread to the lateral neck. METHODS: A retrospective medical chart review of PTC patients treated with lateral neck dissection (levels II-Vb) at our institution between January 2004 and 2011. A total of 185 patients underwent 248 selective lateral neck dissections. RESULTS: Levels II, III, IV, and Vb were respectively involved in 49.3%, 76.6%, 61.6%, and 29.2% of cases. CONCLUSION: We advocate for a routine excision of levels II, III, IV, and Vb in PTC with metastasize to any lateral neck level. Although we have routinely dissected level IIb, it may be appropriate to omit its dissection, as well as level Va, when there are no clinical, radiologic, or intraoperative evidence of disease involving these sublevels.

Outcomes of combined oncologic resection and carotid endarterectomy in patients with head and neck cancer.

BACKGROUND: Patients with head and neck cancer have similar risk factors to patients with carotid disease. Patients with head and neck cancer should be screened with vascular consultations obtained as indicated. Identification of significant carotid artery disease before surgical treatment of head and neck cancer is important in order to prevent perioperative and future strokes. METHODS: Eleven patients underwent carotid duplex ultrasound followed by vascular consultation for significant asymptomatic and symptomatic carotid stenosis. Carotid endarterectomy was performed during an oncologic resection of head and neck cancer between the years of 1996 and 2011. RESULTS: There were no local or regional recurrences. There were no perioperative deaths or strokes. Two-year and 5-year survival were 70% and 29%, respectively, with a median survival of 51 months. CONCLUSION: Collaboration of head and neck surgeons with vascular surgeons provides the patient with an oncologic resection and revascularization with a low perioperative risk of stroke. This improves the patient's quality of life by lessening the possibility of a stroke postoperatively.

Predictors of level II and Vb neck disease in metastatic papillary thyroid cancer.

OBJECTIVE: To identify predictors of levels II and Vb involvement in papillary thyroid cancer (PTC) with lateral neck metastasis. DESIGN: Large case series. SETTING: High-volume tertiary care hospital. PATIENTS: Consecutive sample of 185 patients who underwent 248 selective neck dissections of at least levels II to V for pathologically proven PTC. MAIN OUTCOME MEASURES: Significant independent predictors of level II and Vb metastasis, including age and pathologic variables (tumor diameter, dominant nodule cellular pathology, multifocality, extracapsular invasion, positive margins, and lymphovascular invasion). RESULTS: Levels II and Vb were involved in 49.3% and 29.2% of our cohort, respectively. Age and lymphovascular invasion were independent predictors of level Vb involvement with metastasis (logistic regression: odds ratio for age = 0.92, SE = 0.03, P = .02; and odds ratio for lymphovascular invasion = 5.52, SE = 0.80, P = .03). No significant predictors were identified for level II involvement. CONCLUSIONS: Levels II and Vb were involved in a significant number of patients with PTC and lateral neck disease. Younger age and lymphovascular involvement were independent risk factors for level Vb involvement in patients with PTC and lateral neck metastasis. The increased risk might be of marginal clinical significance. No significant predictors were identified for level II involvement. Our findings do not favor a limited neck dissection on the basis of any of the study's clinical or pathologic variables, and we therefore recommend the routine excision of levels IIa to Vb in all patients with PTC presenting with lateral neck disease.

Carotid resection and reconstruction associated with treatment of head and neck cancer.

Patients with head and neck cancer may experience carotid artery involvement. We present a series of 10 patients, all with stage IVB disease, who required carotid resection and reconstruction to achieve a complete resection. Nine of the 10 patients had previous radiation treatment to the neck. Six died of distant disease, and three died of other causes with no local or regional recurrences. Carotid resection and reconstruction can be done safely, achieving local and regional control.

Parathyroid adenoma on the ipsilateral side of thyroid hemiagenesis.

We present a case of a parathyroid adenoma on the ipsilateral side of thyroid hemiagenesis-which, to our knowledge, is the third reported case of this entity. A 41-year-old man with nephrolithiasis was found to have elevated calcium and intact parathyroid hormone levels. Both ultrasound and technetium sestamibi scintigraphy with single photon emission computed tomography confirmed left thyroid hemiagenesis and an adenoma in the left inferior thyroid bed. The patient underwent left neck exploration, which confirmed left thyroid hemiagenesis and a left inferior parathyroid adenoma. The left inferior parathyroid gland was resected. The patient was discharged home the same day of surgery and has remained normocalcemic for 14 months without evidence of hyperparathyroidism.

Plantar fibromatosis masquerading as metastatic melanoma.

We present the evaluation and treatment of a 59-year-old male with a medical history significant for multiple recurrences of malignant melanoma. The patient was found to have increased focal uptake of his right foot on fluorodeoxyglucose positron emission tomography. Given the patient's clinical history, the increased uptake was suspected to be recurrence of his disease. The nodule was surgically excised and was later pathologically diagnosed as benign plantar fibromatosis. To our knowledge, only one other case report of plantar fibromatosis demonstrating increased fluorodeoxyglucose positron emission tomography uptake exists. Given the distinct prognostic differences between plantar fibromatosis and recurrent malignant melanoma, clinicians should be aware of the possibility of such false-positives with fluorodeoxyglucose positron emission tomography during oncologic surveillance.

Cervicothoracic neuroblastoma arising from the stellate ganglion in children: the use of muscle and bone sparing transmanubrial transcostal approach.

Cervicothoracic neuroblastoma arising from the stellate ganglion in children has always been a challenge to the pediatric surgeon. Localized thoracic neuroblastoma in children has a very good prognosis if excised completely even without adjuvant therapy. Several approaches have been described to resect cervicothoracic neuroblastoma arising from the stellate ganglion with limited success. The muscle and bone sparing transmanubrial transcostal approach which spares the clavicle and the sternomastoid muscle provides excellent exposure for the complete excision of the tumor and excellent functional outcome. We report a 2-year-old girl with cervicothoracic neuroblastoma who had an excellent outcome with this approach.