Gasless endoscopic transaxillary thyroid surgery: CUSUM analysis of a single surgeon's experience from 105 preliminary procedures.

BACKGROUND: We aimed to evaluate the feasibility and oncologic safety of gasless endoscopic transaxillary thyroidectomy (TAT) in patients with thyroid diseases. Improvements in surgical techniques were also reported, and the learning curves of gasless endoscopic TAT were further studied. METHODS: An exact 1:1 matching analysis was performed to compare the technical safety and oncologic outcomes between TAT and conventional open surgery. A questionnaire was designed to evaluate the quality of life of enrolled patients. A cumulative summation analysis was designed for the quantitative estimation of the learning curves. RESULTS: A total of 105 consecutive patients who successfully received endoscopic TAT were retrospectively enrolled in the current study. A standard three-step working space making procedure, an approach that does not free the superficial part of the sternal head of the sternocleidomastoid muscle (SCM, NFSSH) and a "point to line to surface" en bloc procedure utilized in lobectomy with ipsilateral central neck dissection (CND), were introduced in our surgical procedures. The mean operation time in the TAT group was significantly longer than that in the conventional open group (86.9 ± 31.3 vs 44.2 ± 8.3, p < 0.001). Significant differences in the complication rate were not found between the two groups. Discomfort in the anterior neck area and SCM was relieved over time in most cases (verbal response scores (VRSs) were gradually decreased over time). The learning curves for working space making, ipsilateral thyroidectomy and the total endoscopic TAT approach were 45 cases, 25 cases and 42 cases, respectively. The operation time in the proficient group was significantly shorter than that in the learning group (67.0 ± 8.4 vs 112.3 ± 35.7, p < 0.001). VRSs in the SCM were significantly lower in the proficient group (for 1 week: 1.25 ± 0.65 vs 2.40 ± 0.63, p < 0.001; for 1 month: 0.81 ± 0.69 vs 1.81 ± 0.40, p < 0.001). CONCLUSIONS: Gasless endoscopic TAT was safe in a cohort of patients with thyroid diseases, with satisfactory surgical outcomes and cosmetic appearance. The learning curve for endoscopic TAT was approximately 42 cases. The proficiency of the endoscopic TAT approach depended primarily on the proficiency of working space making.

Completion thyroidectomy and lateral neck dissection revealed adhesions in the lateral neck compartment after gasless transaxillary endoscopic thyroidectomy: a case report.

Background: Endoscopic thyroidectomy is effective and safe surgical option for thyroid surgery while providing satisfactory cosmetic results. Gasless transaxillary endoscopic approaches have been reported to achieve endoscopic thyroidectomy in our center. Case Description: We present a patient who previously underwent gasless transaxillary endoscopic lobectomy with ipsilateral central neck dissection who underwent open completion thyroidectomy and lateral neck dissection (LND) (reoperation) in our center. The ultrasound test before the first treatment did not reveal abnormal lymph nodes in the central and lateral neck compartments. Further evaluation of the neck lymph nodes was not performed. Meanwhile, this patient did not participate in the originally planned follow-up at the 3- and 6-month visits. At the one-year visit, imaging tests revealed enlarged and suspicious malignant lymph nodes in levels III and IV of the lateral neck compartments. We believed that reoperation was performed for persistent, rather than truly recurrent disease for this patient. During the second surgery, we found that the surface of internal jugular vein (IJV) was significantly adhered to the surrounding fibroadipose tissue and the omohyoid muscle was adhered to the IJV. After carefully dissected the IJV, the dissection of the lateral neck compartment had been performed successfully. Conclusions: Exposure of the lateral neck compartment in the gasless transaxillary procedure, especially exposure of the IJV, causes adhesions of the lateral neck compartment and brings difficulties for possible future LND. Gasless transaxillary endoscopic thyroid surgery should be performed in strictly selected patients with adequate preoperative assessment. The IJV should be carefully dissected to avoid IJV injury, and the lateral neck compartment could be dissected successfully during reoperation.

Application of Indocyanine Green Angiography in Bilateral Axillo-Breast Approach Robotic Thyroidectomy for Papillary Thyroid Cancer.

Background: Indocyanine green angiography (ICGA) has been used to identify and preserve the parathyroid glands (PGs), and to evaluate PGs viability and function during thyroid surgery. However, evidence on the utilization of IGCA in thyroid cancer and robotic surgery is lacking. The efficacy of IGCA remains to be evaluated in PTC patients undergoing bilateral axillo-breast approach robotic thyroidectomy (BABA RT) and central neck dissection (CND). Methods: From March 2020 to August 2021, 81 papillary thyroid cancer (PTC) patients receiving total thyroidectomy and CND were enrolled in this retrospective analysis. An intravenous bolus of 7.5 mg ICG was administrated three times in the ICGA group (n=34). Medical records were reviewed and analyzed, including the baseline characteristics, surgical parameters, PGs-related parameters, and perioperative PTH and calcium levels. Results: The mean number of total identified PGs and preserved PGs were significantly more in the ICG group than in the control group (3.74 ± 0.45 vs. 3.15 ± 0.55, P<0.001; 3.12 ± 0.64 vs. 2.74 ± 0.57, P=0.007, respectively), as were PTH and calcium levels on POD 1 (23.16 ± 18.32 vs. 6.06 ± 7.74, P=0.039; 2.13 ± 0.11 vs. 2.08 ± 0.08, P=0.024, respectively). While there were no differences in PTH levels on POD 30. Additionally, patients with at least one well vascularized PG had higher ioPTH 3 and PTH on POD 1, which significantly suggested the absence of postoperative hypocalcemia. Although not statistically significant, ICGA seemed superior to relative ioPTH decline and ioPTH 3 in predicting postoperative hypocalcemia. Conclusion: In PTC patients undergoing BABA RT and CND, ICGA is a simple, safe, effective, and cost-effective tool in better identification and preservation of PGs as well as evaluation of PGs viability and function, with the potential to preserve more PGs, guide more appropriate autotransplantation, and accurately predict postoperative hypocalcemia.

Learning curve for robotic thyroidectomy using BABA: CUSUM analysis of a single surgeon's experience.

Background: This study assessed the safety and oncologic outcomes of robotic thyroidectomy via the bilateral axillary breast approach (BABA RT) for conventional open procedures. The learning curves of BABA RT were further evaluated. Methods: An exact 1:1 matching analysis was performed to compare the technical safety and oncologic outcomes between robotic thyroidectomy and conventional open surgery. Learning curves were assessed using cumulative summation analysis. Results: There was no significant difference in general characteristics, short time outcomes (including transient hypoparathyroidism, transient postoperative hoarseness, hematoma/seroma, mean postoperative hospital stay, and other complications), the number of retrieved central lymph nodes, and recurrence rates between robotic BABA and conventional groups. The mean number of retrieved lateral LNs in the robotic group was significantly less than those in the conventional group. The learning curve for working space making, robotic lobectomy, and total thyroidectomy are approximately 15, 30, and 20 cases, respectively. No differences except for operation time were found between the learning group and the proficient group. Conclusions: Robotic thyroidectomy and neck dissection via BABA are feasible in terms of surgical completeness, surgical safety, and oncological safety. Our results provide a criterion for judging whether the surgeon has entered the stable stage of robotic thyroidectomy via BABA in terms of the operative time.

Development and validation of a prognostic nomogram for Hürthle cell thyroid carcinoma: a SEER-based study.

Background: Hürthle cell carcinoma is a rare subtype of thyroid cancer, and its clinical behavior and biological characteristics remain unclear. This study aimed to establish nomogram models for the prognostic evaluation of Hürthle cell thyroid carcinoma (HCTC) in terms of both cancer-specific survival (CSS) and overall survival (OS). Methods: Data for a total of 3,264 patients with HCTC (2004 to 2018) were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox regression analysis was performed to identify significant predictors of prognosis and develop a prognostic nomogram. The performance of the model was assessed based on the area under the receiver operating characteristic curve (AUC), concordance index (c-index), and calibration curves. Results: Multivariate Cox regression analysis showed that age, sex, summary stage, tumor size, N stage, M stage, and treatment with thyroidectomy were independent predictors of OS. Moreover, age, summary stage, tumor size, N stage, M stage, AJCC stage, and treatment with thyroidectomy were significantly correlated with CSS. The c-index of the OS and CSS nomograms developed based on these factors was 0.822 (95% CI: 0.803-0.841) and 0.893 (95% CI: 0.866-0.920), respectively. The AUC was 0.888, 0.841, and 0.834 for 1-, 3-, and 5-year OS and 0.970, 0.949, and 0.933 for 1-, 3-, and 5-year CSS, respectively. The calibration curves showed good agreement between observed and predicted values. Moreover, decision curve analysis revealed that the nomogram had a better clinical utility than individual clinicopathological markers. Conclusions: A prognostic nomogram that allows the individualized assessment of OS and CSS in HCTC was developed. This nomogram could be used to guide treatment decisions in patients with HCTC.

Identification and validation of potential novel biomarkers to predict distant metastasis in differentiated thyroid cancer.

BACKGROUND: Distant metastasis (DM) is not common in differentiated thyroid cancer (DTC). However, it is associated with a significantly poor prognosis. Early detection of high-risk DTC patients is difficult, and the molecular mechanism is still unclear. Therefore, the present study aims to establish a novel predictive model based on clinicopathological parameters and DM-related gene signatures to provide guidelines for clinicians in decision making. METHODS: Weighted gene co-expression network analysis (WGCNA) was performed to discover co-expressed gene modules and hub genes associated with DM. Univariate and multivariate analyses were carried out to identify independent clinicopathological risk factors based on The Cancer Genome Atlas (TCGA) database. An integrated nomogram prediction model was established. Finally, real hub genes were validated using the GSE60542 database and various thyroid cell lines. RESULTS: The midnightblue module was most significantly positively correlated with DM (R=0.56, P=9e-06) by as per WGCNA. DLX5 (AUC: 0.769), COX6B2 (AUC: 0.764), and LYPD1 (AUC: 0.760) were determined to be the real hub genes that play a crucial role in predicting DM. Meanwhile, univariate and multivariate analyses demonstrated that T-stage (OR, 15.03; 95% CI, 1.75-319.40; and P=0.024), histologic subtype (OR, 0.17; 95% CI, 0.03-0.92; and P=0.042) were the independent predictors of DM. Subsequently, a nomogram model was constructed based on gene signatures and independent clinical risk factors exhibited good performance. Additionally, the mRNA expressions of real hub genes in the GSE60542 dataset were consistent with TCGA. CONCLUSIONS: The present study has provided a reliable model to predict DM in patients with DTC. This model is likely to serve as an individual risk assessment tool in therapeutic decision-making.

Endoscopic Lateral Neck Dissection: A New Frontier in Endoscopic Thyroid Surgery.

Background: Endoscopic thyroidectomy and robotic thyroidectomy are effective and safe surgical options for thyroid surgery, with excellent cosmetic outcomes. However, in regard to lateral neck dissection (LND), much effort is required to alleviate cervical disfigurement derived from a long incision. Technologic innovations have allowed for endoscopic LND, without the need for extended cervical incisions and providing access to remote sites, including axillary, chest-breast, face-lift, transoral, and hybrid approaches. Methods: A comprehensive review of published literature was performed using the search terms "lateral neck dissection", "thyroid", and "endoscopy OR endoscopic OR endoscope OR robotic" in PubMed. Results: This review provides an overview of the current knowledge regarding endoscopic LND, and it specifically addresses the following points: 1) the surgical procedure, 2) the indications and contraindications, 3) the complications and surgical outcomes, and 4) the technical advantages and limitations. Robotic LND, totally endoscopic LND, and endoscope-assisted LND are separately discussed. Conclusions: Endoscopic LND is a feasible and safe technique in terms of complete resection of the selected neck levels, complications, and cosmetic outcomes. However, it is recommended to strictly select criteria when expanding the population of eligible patients. A formal indication for endoscopic LND has not yet been established. Thus, a well-designed, multicenter study with a large cohort is necessary to confirm the feasibility, long-term outcomes, oncological safety, and influence of endoscopic LND on patient quality of life (QoL).

The Role of m6A RNA Methylation-Related lncRNAs in the Prognosis and Tumor Immune Microenvironment of Papillary Thyroid Carcinoma.

Emerging evidence has indicated that N6-methylandenosine (m6A) RNA methylation plays a critical role in cancer development. However, the function of m6A RNA methylation-related long noncoding RNAs (m6A-lncRNAs) in papillary thyroid carcinoma (PTC) has never been reported. This study aimed to investigate the role of m6A-lncRNAs in the prognosis and tumor microenvironment (TME) of PTC. Three subgroups (clusters 1, 2, and 3) were identified by consensus clustering of 19 prognosis-related m6A-lncRNA regulators, of which cluster 1 is preferentially related to unfavorable prognosis, lower immune scores, and distinct immune infiltrate level. A risk-score model was established based on 8 prognosis-related m6A-lncRNAs. Patients with a high-risk score showed a worse prognosis, and the ROC indicated a reliable prediction performance for patients with PTC (AUC = 0.802). As expected, the immune scores, the infiltration levels of immune cells, and ESTIMATE scores in the low-risk subgroups were notably higher (p < 0.001) when compared with those in high-risk subgroups. Furthermore, GSEA analysis revealed that tumor associated pathways, hallmarks, and biological processes were remarkably enriched in the high-risk subgroup. Further analysis indicated that the risk score and age were independent prognostic factors for PTC. An integrated nomogram was constructed that accurately predicted the survival status (AUC = 0.963). Moreover, a lncRNA-miRNA-mRNA regulated network was established based on seven prognosis-related m6A-lncRNAs. In addition, 30 clinical samples and different PTC cells were validated. This is the first study to reveal that m6A-lncRNAs plays a vital role in the prognosis and TME of PTC. To a certain degree, m6A-lncRNAs can be considered as new, promising prognostic biomarkers and treatment targets.

Prediction of level V metastases in papillary thyroid microcarcinoma: a single center analysis.

BACKGROUND: The rate of level V metastases is significantly low and the necessity of routine level V dissection for papillary thyroid microcarcinoma (PTMC) with clinically lateral lymph node metastasis (LNM) is still controversial. METHODS: This study enrolled 114 consecutive PTMC patients with clinically suspected lateral LNM (N1b) who underwent modified radical neck dissection (levels II to V) at Xiangya Hospital of Central South University from September 2016 to July 2019. Univariate and multivariate analyses were performed to investigate the predictive factors of level V metastasis. The area under the receiver operating characteristic (ROC) curve (AUC), accuracy, specificity and sensitivity were used to determine the predictive value. RESULTS: The overall and occult rate of level V metastasis were 29.82% (34/114) and 7.02% (8/114), respectively. Univariate analysis showed that level V metastasis was significantly associated with gross extrathyroidal extension (ETE), level IV metastasis and 2-level simultaneous metastasis (all P<0.05). Gross ETE (OR =11.916, 95% CI, 1.404-102.19; P=0.023) and level IV metastasis (OR =8.497, 95% CI, 2.119-34.065; P =0.03) served as independent predictors of level V metastasis in N1b PTMC patients. The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of gross ETE and level IV metastasis in predicting the level V metastasis were 25.3% vs. 82.4%, 97.5% vs. 73.8%, 82.69% vs. 76.32%, 80% vs. 57.04% and 75% vs. 90.77%, respectively. The AUC of gross ETE was lower than level IV metastasis (0.605 vs. 0.781, P=0.041). CONCLUSIONS: Routine level V dissection is necessary in N1b PTMC patients with level IV metastasis or gross ETE. Compared with gross ETE, level IV metastasis is superior in predicting level V metastasis.

Sequencing and Analysis of Strobilanthes cusia (Nees) Kuntze Chloroplast Genome Revealed the Rare Simultaneous Contraction and Expansion of the Inverted Repeat Region in Angiosperm.

Ban-Lan-Gen, the root tissues derived from several morphologically indistinguishable plant species, have been used widely in traditional Chinese medicines for numerous years. The identification of reliable markers to distinguish various source plant species is critical for the effective and safe use of products containing Ban-Lan-Gen. Here, we analyzed and characterized the complete chloroplast (cp) genome sequence of Strobilanthes cusia (Nees) Kuntze to identify high-resolution markers for the species determination of Southern Ban-Lan-Gen. Total DNA was extracted and subjected to next-generation sequencing. The cp genome was then assembled, and the gaps were filled using PCR amplification and Sanger sequencing. Genome annotation was conducted using CpGAVAS web server. The genome was 144,133 bp in length, presenting a typical quadripartite structure of large (LSC; 91,666 bp) and small (SSC; 17,328 bp) single-copy regions separated by a pair of inverted repeats (IRs; 17,811 bp). The genome encodes 113 unique genes, including 79 protein-coding, 30 transfer RNA, and 4 ribosomal RNA genes. A total of 20 tandem, 2 forward, and 6 palindromic repeats were detected in the genome. A phylogenetic analysis based on 65 protein-coding genes showed that S. cusia was closely related to Andrographis paniculata and Ruellia breedlovei, which belong to the same family, Acanthaceae. One interesting feature is that the IR regions apparently undergo simultaneous contraction and expansion, resulting in the presence of single copies of rps19, rpl2, rpl23, and ycf2 in the LSC region and the duplication of psbA and trnH genes in the IRs. This study provides the first complete cp genome in the genus Strobilanthes, containing critical information for the classification of various Strobilanthes species in the future. This study also provides the foundation for precisely determining the plant sources of Ban-Lan-Gen.