Geographic disparities in thyroid cancer staging at presentation: Insights from an Australian context.

BACKGROUND: Thyroid cancer diagnoses have increased over recent decades at a rate much higher than that of any other cancer in Australia. Rural patients are known to have reduced access to healthcare and may have different thyroid cancer presentation rates. This study examined the relationship between thyroid cancer diagnosis and patient rurality. METHODS: Data from the Australia and New Zealand Thyroid Cancer Registry from 2017 to 2022 were analyzed, stratifying patient postcodes into rurality groups using the Australian Statistical Geography Standard. The American Thyroid Association (ATA) guidelines were used to stratify risk categories and management to compare treatment adequacy between the groups. Statistical analysis assessed demographic, clinical, and management differences. RESULTS: Among 1766 patients, 70.6% were metropolitan (metro) and 29.4% were non-metropolitan (non-metro). Non-metro patients were older at diagnosis (median 56 vs. 50 years, p < 0.001), presented more frequently with T stage greater than 1 (stage 2-4, 41.9% vs. 34.8%, and p = 0.005), AJCC stage greater than 1 (stage 2-4, 18.5% vs. 14.6%, and p = 0.019), and cancers larger than 4 cm (14.3% vs. 9.9%, p = 0.005). No significant differences in treatment adequacy were observed between the groups for ATA low-risk cancers. CONCLUSIONS: Non-metropolitan patients in the registry present with more advanced thyroid cancer, possibly due to differences in healthcare access. Further research should assess long-term survival outcomes and influencing factors. Understanding the impact on patient outcomes and addressing healthcare access barriers can optimize thyroid cancer care across geographic regions in Australia.

Artificial Intelligence for Pre-operative Diagnosis of Malignant Thyroid Nodules Based on Sonographic Features and Cytology Category.

BACKGROUND: Current diagnosis and classification of thyroid nodules are susceptible to subjective factors. Despite widespread use of ultrasonography (USG) and fine needle aspiration cytology (FNAC) to assess thyroid nodules, the interpretation of results is nuanced and requires specialist endocrine surgery input. Using readily available pre-operative data, the aims of this study were to develop artificial intelligence (AI) models to classify nodules into likely benign or malignant and to compare the diagnostic performance of the models. METHODS: Patients undergoing surgery for thyroid nodules between 2010 and 2020 were recruited from our institution's database into training and testing groups. Demographics, serum TSH level, cytology, ultrasonography features and histopathology data were extracted. The training group USG images were re-reviewed by a study radiologist experienced in thyroid USG, who reported the relevant features and supplemented with data extracted from existing reports to reduce sampling bias. Testing group USG features were extracted solely from existing reports to reflect real-life practice of a non-thyroid specialist. We developed four AI models based on classification algorithms (k-Nearest Neighbour, Support Vector Machine, Decision Tree, Naïve Bayes) and evaluated their diagnostic performance of thyroid malignancy. RESULTS: In the training group (n = 857), 75% were female and 27% of cases were malignant. The testing group (n = 198) consisted of 77% females and 17% malignant cases. Mean age was 54.7 ± 16.2 years for the training group and 50.1 ± 17.4 years for the testing group. Following validation with the testing group, support vector machine classifier was found to perform best in predicting final histopathology with an accuracy of 89%, sensitivity 89%, specificity 83%, F-score 94% and AUROC 0.86. CONCLUSION: We have developed a first of its kind, pilot AI model that can accurately predict malignancy in thyroid nodules using USG features, FNAC, demographics and serum TSH. There is potential for a model like this to be used as a decision support tool in under-resourced areas as well as by non-thyroid specialists.

Patient Reported Experience on Consenting for Surgery - Elective Versus Emergency Patients.

INTRODUCTION: Informed consent for surgery is a medical and legal requirement, but completing these does not necessarily translate to high patient satisfaction. This patient-reported experience study aimed to examine the surgical consent process, comparing the patients' experience in elective and emergency settings. METHODS: Over a 6-mo period, postoperative patients at The Alfred Hospital Breast and Endocrine Surgical Unit were invited to participate in a survey on the surgical consent process - including perceived priorities, information provided and overall experience. Standard statistical techniques were used, with a significant P-value of < 0.05. RESULTS: A total of 412 patients were invited, with 130 (32%) responses. More patients underwent elective surgery (N= 90, 69%) than emergency surgery (N = 40, 31%). Emergency patients were more likely to sign the consent form regardless of its contents (93% versus 39%, P < 0.001) and more likely to be influenced by external pressures (63% versus 1%, P < 0.001). Elective patients were more likely to want to discuss their surgery with a senior surgeon (74% versus 23%, P < 0.001) and more likely to seek advice from external sources (83% versus 10%, P < 0.001). Both groups highly valued the opportunity to ask questions (67% versus 63%, P = 0.65). CONCLUSION: This study shows patients have a range of different priorities in preparation for surgery. Therefore, each consent process should be patient-specific, and focus on providing the patient with quality resources that inform decision-making.

Anti-Thyroid Antibodies and TSH as Potential Markers of Thyroid Carcinoma and Aggressive Behavior in Patients with Indeterminate Fine-Needle Aspiration Cytology.

BACKGROUND: Indeterminate fine-needle aspiration cytology (FNAC) imposes challenges in the management of thyroid nodules. This study aimed to examine whether preoperative anti-thyroid antibodies (Abs) and TSH are indicators of thyroid malignancy and aggressive behavior in patients with indeterminate FNAC. METHODS: This was a retrospective study of thyroidectomy patients from 2008 to 2016. We analyzed Abs and TSH levels, FNAC, and histopathology. Serum antibody levels were categorized as 'Undetectable', 'In-range' if detectable but within normal range, and 'Elevated' if above upper limit of normal. 'Detectable' levels referred to 'In-range' and 'Elevated' combined. RESULTS: There were 531 patients included. Of 402 patients with preoperative FNAC, 104 (25.9%) had indeterminate cytology (Bethesda III-V). Of these, 39 (37.5%) were malignant and 65 (62.5%) benign on histopathology. In the setting of indeterminate FNAC, an increased risk of malignancy was associated with 'Elevated' thyroglobulin antibodies (TgAb) (OR 7.25, 95% CI 1.13-77.15, P = 0.01) and 'Elevated' thyroid peroxidase antibodies (TPOAb) (OR 6.79, 95% CI 1.23-45.88, P = 0.008). Similarly, while still 'In-range', TSH ≥ 1 mIU/L was associated with an increased risk of malignancy (OR 3.23, 95% CI 1.14-9.33, P = 0.01). In all patients with malignancy, the mean tumor size was 8 mm larger in those with TSH ≥ 1 mIU/L (P = 0.03); furthermore, in PTC patients, 'Detectable' TgAb conferred a 4 × risk of lymph node metastasis (95% CI 1.03-13.77, P = 0.02). CONCLUSION: In this cohort, in indeterminate FNAC patients, Abs and TSH were associated with an increased risk of malignancy. Additionally, TgAb and TSH were potential markers of aggressive biology. As such, they may be diagnostic and prognostic adjuncts.

Thyroidectomy Then and Now: A 50-Year Australian Perspective.

BACKGROUND: Since the mid-1800s, thyroidectomy has transformed from a procedure associated with high to near-zero mortality. Nonetheless, surgeons must continue to strive to improve patient care. Using historical records and contemporary data, this study compares the practice and outcomes of thyroid surgery at a tertiary institution during two periods, 50 years apart. METHODS: 'The Alfred Hospital Clinical Reports' recorded all cases of surgically managed thyroid disease from 1946 to 1959. These historical cases were compared to contemporary thyroidectomy cases at the Alfred Hospital from 2007 to 2016. Cases were compared for surgical indication and post-operative outcomes. RESULTS: There were 746 patients in the historical group (mean age 53 years; 87% female) and 787 patients in the contemporary group (mean age 52 years; 80% female). The most common indication for thyroidectomy in both groups was non-toxic nodular goitre. A greater proportion of the contemporary group were diagnosed with thyroid malignancy (27% vs. 8%; p < 0.001). The contemporary group recorded significantly fewer cases of thyrotoxic crisis (2.1% vs. 0%; p = 0.001), permanent nerve palsy (4.6% vs. 0.4%; p < 0.001) and bilateral nerve palsy (1.2% vs. 0%; p = 0.01). There were no mortalities in the contemporary group, while the historical data recorded three deaths (0.44%). CONCLUSIONS: This study compared thyroid surgery in two cohorts separated by a 50-year period. While it is not surprising that outcomes of thyroidectomy have improved, this study uniquely demonstrates trends of thyroid surgery over time and areas in which further improvements may be made.

Fine-needle aspiration of the thyroid: correlating suspicious cytology results with histological outcomes.

PURPOSE: Fine-needle aspiration cytology (FNAC) assists the diagnosis of thyroid malignancy. A 'suspicious for malignancy' on FNAC creates a management dilemma. The aims of this study were to investigate the malignancy rate for patients with suspicious cytology, and to describe a management approach for those with a suspicious result. METHODOLOGY: A retrospective review of prospectively collected data in an endocrine surgery database was undertaken. Patients undergoing thyroidectomy with preoperative FNAC from 1992 to 2012 were analysed. RESULTS: Preoperative FNAC was undertaken in 2,692 patients, and the FNAC result was 'suspicious for malignancy' in 94 (3.5 %) patients. Of these, 53 (56.4 %) were malignant, with the majority 44 (83.0 %) being papillary thyroid cancer. 48 patients went straight to total thyroidectomy, 40 patients had an initial diagnostic hemithyroidectomy, and 1 patient had a diagnostic isthmusectomy. 5 patients required reoperative total thyroidectomy as an initial procedure. Of the 94 suspicious cases, 55 were reported by an unknown, presumably non-expert, thyroid cytopathologist. 38 of these cases were available for review and re-reporting by an experienced cytopathologist. On review, 28 (73.7 %) were reclassified as cytologically malignant, and all of these were confirmed as malignant on subsequent histopathology. CONCLUSIONS: Suspicious cytology has a high risk of malignancy. Expert thyroid cytopathology can improve diagnostic accuracy and a preoperative malignant diagnosis should be pursued to enable one-stage surgery where possible.

The prevalence of thyroglossal tract thyroid tissue on SPECT/CT following (131) I ablation therapy after total thyroidectomy for thyroid cancer.

OBJECTIVE: To determine the prevalence of thyroglossal tract thyroid tissue on SPECT/CT and to assess the contribution of this tissue to total neck radioactive iodine (RAI) activity in patients given (131) I ablation therapy after total thyroidectomy for thyroid cancer. PATIENTS AND METHODS: Eighty-three consecutive patients with thyroid cancer treated with total thyroidectomy underwent whole-body planar and SPECT/CT imaging of the neck following initial RAI ablation. On SPECT/CT, thyroglossal tract thyroid tissue was defined as RAI in the anterior neck, superior to the thyroid bed in close proximity to the midline without evidence of localization to lymph nodes. Quantification was performed using region of interest analysis on planar imaging following localization on SPECT/CT. SPECT/CT, and planar images were classified by two reviewers as positive, negative or equivocal with interobserver agreement quantified using a Kappa score. Disagreement was resolved using a third reviewer. RESULTS: Thyroglossal tract thyroid tissue was present in 39/83 (47%; 95%CI: 36-58%) patients on SPECT/CT. In these 39 patients, this tissue contributed to a significant amount of total neck activity (median = 50%; IQR 19-74%). Interobserver agreement for the presence of thyroglossal tract thyroid tissue was substantial on SPECT/CT (Kappa = 0.73) and fair on planar imaging (Kappa = 0.31). CONCLUSION: Thyroglossal tract thyroid tissue was present in one half of our study population and contributed to a significant amount of total neck RAI activity. Given the high prevalence of this tissue, our results suggest that total neck RAI activity on planar imaging may not be suitable to assess the completeness of thyroid bed surgery.

Preoperative serum calcitonin may improve initial surgery for medullary thyroid cancer in patients with indeterminate cytology.

BACKGROUND: Medullary thyroid cancer (MTC) is rare, with poorer outcomes than differentiated thyroid cancer. We aimed to identify areas for improvement in the pre-operative evaluation of patients with possible MTC in a high-volume endocrine surgery unit in accordance with current practice guidelines. We hypothesised that the selective use of serum calcitonin (sCT) as a biomarker for possible MTC could guide the extent of initial surgical management. METHODS: We recruited MTC patients between 2000 and 2020 from the Monash University Endocrine Surgery Unit database. Demographics, tumour characteristics, pre-operative evaluation, operative management, and outcomes were analysed. RESULTS: Of 1454 thyroid cancer patients, 43 (3%) had MTC. Pre-operatively, 36 (84%) patients with MTC confirmed on cytology (28, 65%), elevated sCT (6, 14%) or RET mutation (2, 4%). Of these 36 patients, 31 (86%) had optimal extent of thyroidectomy and lymph node dissection (LND). Five (14%) had less than total thyroidectomy due to nerve injury. Thirty-four patients had compartmental LND. In the 12 (27%) patients with indeterminate or non-diagnostic cytology, 5 had elevated sCT and were managed as above. None of the remaining seven had LND, thus potentially suboptimal surgery. CONCLUSION: Our findings reflect the rarity of MTC, and the challenges of pre-operative diagnosis. The addition of sCT may improve surgical planning in patients with indeterminate cytology.

Recurrent laryngeal nerve diameter increases during thyroidectomy.

BACKGROUND: Temporary recurrent laryngeal nerve (RLN) palsy after thyroidectomy is usually due to a neurapraxia. Voice changes after thyroidectomy, in the absence of RLN palsy, are common. We postulated that this is due to edema and consequent increased diameter of the RLN during thyroidectomy. The aim of this study was to document changes in the diameter of the RLN during surgery. METHODS: A consecutive series of 110 RLNs was prospectively analyzed in 75 patients. The RLN was measured on identification and removal of the lobe. Electromyogram (EMG) amplitudes were recorded concurrently after neurostimulation. Univariate and multivariate analyses were performed. RESULTS: The mean increase in RLN diameter was 0.71 from 1.95 mm (P < 000.1). Right and left RLNs were similar diameter. On univariate and multivariate analysis, factors predictive of increased RLN diameter were increasing age (P = 0.04) and increased difference in EMG amplitude (P = 0.01). There was a mean increased EMG amplitude of 101 from 493.5 µV (P < 0.001). On univariate and multivariate analyses, factors predictive of increased difference in EMG amplitude were decreasing age (P = 0.01) and increased difference in RLN diameter (P = 0.02). There was a statistically significant positive relationship between increased diameter of RLN and increased EMG amplitude (R(2) = 0.04). The temporary RLN palsy rate was 3%. CONCLUSIONS: The small numbers of temporary RLN palsies prevent correlation with increased diameter of RLN. However, this may explain voice changes after thyroidectomy without RLN palsy. The observed increase in RLN diameter is probably due to edema; its cause is unknown. The increased EMG amplitude seen with increasing RLN diameter may reflect increased excitability of ionic channels in neurons.

New operative surgical concept of two fascial layers enveloping the recurrent laryngeal nerve.

BACKGROUND: Avoiding recurrent laryngeal nerve (RLN) injury is aided by a precise anatomical understanding of the RLN before entry into the larynx where it is at greatest risk. METHODS: A literature review and study of 977 RLNs at operation have been used to describe the last 2 cm of the anatomical course of the extralaryngeal RLN. RESULTS: The tertiary branches of the inferior thyroid artery pass in a superficial vascular fascial layer anterolateral to the RLN. The tubercle of Zuckerkandl and the superior parathyroid glands lie within this superficial vascular fascial covering layer. The RLN lies on a deeper layer of more fibrous tissue, the ligament of Berry. In all 977 RLNs, the RLN was sandwiched between an anterolateral vascular layer and a medial layer, the ligament of Berry. CONCLUSIONS: The site of greatest risk during thyroidectomy to the RLN is in the 2-cm course of the extralaryngeal nerve above the trunk of the inferior thyroid artery where tension forms an artificial genu of the nerve. Once the superficial vascular fascial and Berry's ligament layers are released, the nerve falls back into the tracheoesophageal groove and adopts a serpiginous appearance, indicating completeness of the dissection of the lobe from the lateral trachea and division of the ligament of Berry.

Investigation of recurrent laryngeal palsy rates for potential associations during thyroidectomy.

BACKGROUND: There are many clinical associations and potential mechanisms of injury resulting in recurrent laryngeal nerve palsy (RLNP) after thyroidectomy. One possible cause of RLNP is focal intralaryngeal compression of the recurrent laryngeal nerve (RLN), which may be associated with the tracheal tube (TT). Therefore, we examined current RLNP rates to investigate potential associations, including intralaryngeal, airway, anaesthetic and anthropometric factors. METHODS: We analysed 1003 patients undergoing thyroid surgery at The Alfred from 2010 to 2017, who had anatomically intact RLNs at the conclusion of thyroidectomy. All included patients underwent pre- and post-operative flexible nasendoscopy. The primary outcome was RLNP rate. We analysed potential associated factors including age, sex, operative time, surgical indication, pathology, American Society of Anaesthesiologists Physical Status, Mallampati scores, body mass index, intubation grade, TT size and specimen weight. The independent risk factors were identified by logistic regression analysis. RESULTS: Overall, RLNP occurred in 83 patients (8.3%) of which one was permanent (0.1%). On univariate analysis, RLNP was associated with male sex (P = 0.02), and duration of surgery (P = 0.002). On multivariate analysis, both male sex (P = 0.047) and duration of surgery (P = 0.04) remained significant. Further, factors postulated to cause intralaryngeal compression of the RLN, including TT size, body mass index, intubation grade and Mallampati score, were not significantly associated with RLNP. CONCLUSION: Our study showed a RLNP rate of 8.3%, and associations with longer operative duration, and male sex. Potential intralaryngeal factors were not identified.

The motor fibers of the recurrent laryngeal nerve are located in the anterior extralaryngeal branch.

OBJECTIVE: This study aimed to establish the prevalence of extralaryngeal bifurcation of the recurrent laryngeal nerve (RLN) and investigate the location of the motor fibers to the intrinsic muscles of the larynx within the branches of the RLN. SUMMARY OF BACKGROUND DATA: Recognition of extralaryngeal branching of the RLN is important, because inadvertent division of a branch may lead to significant vocal cord palsy despite the operator believing the nerve was preserved. METHODS: Prospective operative data on branching of the RLN were collected in 579 patients undergoing thyroidectomy or open parathyroidectomy over a 3 year period and nerve integrity monitoring was utilized to document the position of the motor fibers of the last 176 RLNs. Adduction of the vocal cords was detected by the electromyography-endotracheal tube and abduction by finger palpation of muscle contraction in the posterior cricoarytenoid. RESULTS: A total of 838 RLN were studied (right--432, left--406). Bifurcations occurred on the right in 111 (25.7%) and left 93 (22.9%). Bilateral bifurcation occurred in 23 (8.9%) of bilaterally dissected nerves. Overall 176 RLNs in 118 patients were assessed by the nerve integrity monitoring. Of these 41 (23.3%) were bifid RLN. In all 41 (100%) cases of bifid RLN, motor fibers for both adduction and abduction of the vocal cords were located exclusively in the anterior branches of RLN, and none in the posterior branches. CONCLUSION: Extralaryngeal bifurcation of RLN is a common anatomical variant. The motor fibers of RLN are located in the anterior branch, for both adduction and abduction. Great care is therefore required following the presumed identification of the RLN to ensure there is no unidentified anterior branch.

Hypothyroidism following hemithyroidectomy: a retrospective review.

OBJECTIVE: To investigate the incidence, time to onset, and risk factors for the development of hypothyroidism after hemithyroidectomy. BACKGROUND: The incidence and risk factors for hypothyroidism in patients undergoing partial thyroid surgery remains unclear. Hypothyroidism is an under appreciated sequel of hemithyroidectomy. The early recognition of this postoperative complication may prevent symptoms of hypothyroidism and recurrent thyroid disease. METHODS: We conducted a retrospective review of all patients undergoing hemithyroidectomy from August 1992 to June 2006 by a single surgeon. Patients were analyzed for age, sex, family history of thyroid disease, thyroid antibody levels, pre- and postoperative thyroid stimulating hormone (TSH), histologic diagnosis, weight of resected tissue, histologic evidence of thyroiditis, and lag time to diagnosis of hypothyroidism. chi or Fisher exact test or Student t test were performed. RESULTS: Hypothyroidism was diagnosed in 10.9% of 294 patients. The mean time to diagnosis was 8.2 +/- 10.9 months. The mean thyroxine dose was 69.4 +/- 31.6 micrograms. Patients with postoperative hypothyroidism had a higher incidence of a high-normal preoperative TSH level (TSH: 2.5-4.0 mIU/L, 18.8% vs. 3.8%; P < 0.01), thyroiditis on histology (46.8% vs. 11.8%; P < 0.01) and elevated thyroid antibodies levels (47.8% vs. 11.5%; P < 0.01). Age, gender, family history of thyroid disease, thyroid pathology, and weight of resected tissue were not significant risk factors for hypothyroidism. CONCLUSIONS: An incidence of 10.9% is higher than anticipated and all patients should have postoperative thyroid function assessment. However, a high-normal preoperative TSH, elevated thyroid antibody levels, and the presence of thyroiditis on histology are indications for close monitoring.

Routine Preoperative Laryngoscopy for Thyroid Surgery Is Not Necessary Without Risk Factors.

Background: Routine preoperative vocal cord (VC) assessment with laryngoscopy in patients undergoing thyroidectomy allows clear documentation of baseline VC function, aids in surgical planning in patients with palsies, and facilitates interpretation of intraoperative neuromonitoring (IONM) findings. We aimed to determine the incidence of preoperative vocal cord palsy (VCP); to evaluate the associated risk factors for preoperative VCP; and to calculate the cost-savings potential of implementing a selective approach. Methods: Patients with a pre-thyroidectomy VC assessment by fiberoptic laryngoscopy were retrospectively recruited from the Monash University Endocrine Surgery Unit database from 2000 to 2018. Cases with preoperative VCP were reviewed for potential contributing factors and compared with a non-palsy cohort. Results: Of the 5987 patients who had preoperative laryngoscopy, VCP was documented in 41 (0.68%) patients. Four clinical parameters were found to be potential indicators of VCP, including: age (p < 0.001), nodule ≥3.5 cm recorded on ultrasound imaging (p = 0.01), presence of voice symptoms (p < 0.001), and previous neck surgery (p < 0.001). Malignant cytology (p = 0.5) and exposure to head and neck irradiation were not different between the groups. Utilizing these risk factors, 2354 (39%) patients had at least one feature that may raise suspicion for preoperative VCP. By performing preoperative laryngoscopy only on this subset of patients, the potential cost savings exceeds 400 Australian Dollars per patient. Conclusions: Using this large dataset, we have established that a VCP is rare in the absence of a large nodule, hoarseness, or previous neck surgery. Therefore, in the era of IONM, we support a selective approach to preoperative laryngoscopy by using the aforementioned criteria.

Adrenal incidentaloma follow-up is influenced by patient, radiologic, and medical provider factors: A review of 804 cases.

BACKGROUND: The majority of adrenal incidentalomas are benign, although some are large, functional, or malignant and may require surgery. Therefore all require follow-up. This study aimed to determine the pattern of adrenal incidentaloma follow-up in a level 1 trauma center, focusing on the factors that influence whether follow-up is facilitated. METHODS: Patients with computed tomography-detected adrenal incidentalomas between January 2010 and September 2015 were included. A keyword search identified case files, which were reviewed for demographic characteristics, managing unit, computed tomography indication and findings, and follow-up arrangements. Statistical analysis was performed using Stata SE Version 14. RESULTS: A total of 38,848 chest and abdominal computed tomographic scans were performed in the study period, revealing 804 patients with adrenal incidentalomas who met inclusion criteria (mean age 65, 58% male). The mean size of adrenal incidentaloma was 23 mm. Follow-up was organized in 30% of cases and was more likely to occur in younger patients (mean age 62 vs 66, P < .001); in larger lesions (mean size 26 mm vs 21 mm, P < .001); if the computed tomographic scan suggested follow-up (P < .001); or if the computed tomography report suggested a diagnosis (P < .001). Follow-up arrangements were most likely to be made by the trauma unit (39%, P = .01). CONCLUSION: This study highlights that adrenal incidentalomas follow-up is often overlooked, and that follow-up is influenced by patient, radiologic, and medical provider factors. An adrenal lesion follow-up protocol may improve follow-up rates but requires further analysis.

Body weight change is unpredictable after total thyroidectomy.

BACKGROUND: There is a common perception that total thyroidectomy causes weight gain beyond expected age-related changes, even when thyroid replacement therapy induces a euthyroid state. The aim of this study was to determine whether patients who underwent total thyroidectomy for a wide spectrum of conditions experienced weight gain following surgery. METHODS: We retrospectively studied 107 consecutive total thyroidectomy patients treated between January 2013 and June 2014. Medical records were reviewed to determine underlying pathology, thyroid status, use of antithyroid drugs and preoperative weight. Follow-up data were obtained from 79 patients at least 10 months post-operatively to determine current weight, the type of clinician managing thyroid replacement therapy and patient satisfaction with post-thyroidectomy management. RESULTS: The cohort was 73% female, with a mean age of 55.8 ± 15.7 years and a mean preoperative weight of 78.8 ± 17.5 kg. Commonest pathologies were multinodular goitre, Graves' disease, thyroid cancer and Hashimoto's thyroiditis. Preoperatively, 63.2% of patients were hyperthyroid. Mean weight change at follow-up was a non-significant increase of 0.06 ± 6.9 kg (P = 0.094). Weight change was not significant regardless of preoperative thyroid function status. This study did not demonstrate any significant differences in clinical characteristics (including post-operative thyroid-stimulating hormone) between the group with >2% weight gain and those who did not. CONCLUSIONS: This study did not reveal significant weight gain following thyroidectomy for a wide spectrum of pathologies. Specifically, preoperative hyperthyroidism, female gender and use of antithyroid medications do not predict weight gain after thyroid surgery.

Review of large deep lipomatous tumours.

BACKGROUND: Lipomatous tumours comprise a range of diagnoses. There are controversies regarding the histopathological diagnosis, nomenclature, diagnostic method, surgical management, roles of radiotherapy and the risk of metastasis, local recurrence and dedifferentiation. This study describes our experience with such tumours. METHODS: Retrospective review of 224 soft tissue tumours from the Senior Author's (J. W. S.) database identified 28 patients with deep lipomatous tumours. Clinical features and outcomes were studied with median follow up of 1.5 years. RESULTS: Eleven deep lipomas, six deep atypical lipomas, four well-differentiated (lipoma-like) liposarcomas, three well-differentiated liposarcomas and four liposarcomas were studied. Preoperative diagnosis was established by image-guided core biopsy in 20 patients, excisional biopsy in 6, incisional biopsy in 1 and fine-needle aspiration in 1. All patients diagnosed with deep lipoma and deep atypical lipoma underwent marginal excision. The median size of the excised tumour was 11 cm. Recurrence occurred in three deep atypical lipomas and one liposarcoma. Dedifferentiation occurred in one deep atypical lipoma, which transformed into a liposarcoma. None had metastasis or died of metastatic malignancy. CONCLUSION: Large deep lipomatous tumours are uncommon and although they do not tend to metastasize, they not infrequently recur locally. Hence their local treatment to prevent local recurrence is important. Key aspects in achieving a complete, but marginal resection of the deep atypical lipoma and the well-differentiated lipoma-like liposarcoma is accurate preoperative diagnosis with core biopsy and accurate imaging to assess deep unsuspected extensions of the tumour.

Safety of total thyroidectomy.

BACKGROUND: Total thyroidectomy is the preferred operation for multinodular goitre, Graves' disease and thyroid cancer. This study reviewed prospectively collected data on a personal consecutive series of 336 total thyroidectomies to assess whether results reported in world centres of excellence could also be achieved elsewhere. METHODS: Between 1991 and 2004, 336 total thyroidectomies (85% over the last 6 years) of median age 53 years (13-86 years) and male : female ratio of 1:4.3 were undertaken for multinodular goitre 232 (69%), Graves' disease 26 (7.7%), thyroid cancer 60 (17.9%) and other benign conditions 17 (5.4%). Thirty-nine patients had 2-stage procedures. No patient required median sternotomy. Parathyroid autotransplantation was carried out in 43 (12.8%). RESULTS: Permanent unilateral recurrent laryngeal nerve palsy occurred in 0.3% and permanent hypoparathyroidism in 1.8%. Significant temporary hypocalcaemia occurred in 13.4%. Non-significant temporary hypocalcaemia occurred in 23.8%, resulting in an overall rate of hypocalcaemia of 38.9% for the total series. Hypocalcaemia was more common after 1-stage compared with 2-stage surgeries (P < 0.001). Temporary hypocalcaemia was commoner after surgery for Graves' disease than surgery for other conditions. The rate of postoperative haemorrhage was 0.9% and wound infection, 1.5%. There was no postoperative mortality. CONCLUSION: Total thyroidectomy removes the disease process completely, lowers local recurrence rates and avoids the substantial risks of reoperative surgery. Total thyroidectomy is safe and can be carried out with low complication rates that are equal to world centres of excellence.

The impact of synoptic cytology reporting on fine-needle aspiration cytology of thyroid nodules.

BACKGROUND: Fine-needle aspiration cytology (FNAC) is integral to the diagnosis and management of patients with thyroid nodules. We introduced synoptic cytology reporting for thyroid nodules in 2004. The aim of this study was to examine the effect of synoptic cytology reporting in our institution. METHODS: A comparative study of two 2-year periods (1 August 2002 to 1 August 2004 and 2 August 2004 to 2 August 2006) before and after the introduction of synoptic reporting was conducted from a prospectively collected database of patients presented with thyroid nodules. The only change during these periods was the format of FNAC reporting. We used the same radiological practice and cytopathology service throughout the study period. All patients are still being followed up. RESULTS: There were a total of 660 patients. Of these, 376 were operated and 284 non-operated. The female to male ratio was 7:1. Comparing the two periods, the overall FNAC sensitivities were 60% versus 79.1%; specificities, 83.7% versus 79.4%; accuracy, 76% versus 79.3%; false-positive result, 16.3% versus 20.6% and false-negative result, 40% versus 20.9%. The non-diagnostic rates were 7.4% versus 3.15%. FNAC prompted surgery in 66.7% versus 100% in carcinoma and 56.4% versus 73.6% in adenoma. A benign FNAC prompted surgery in 15% versus 19.8% of cases. There was no thyroid cancer detected in the current follow up. CONCLUSIONS: Synoptic cytology reporting has resulted in an overall improvement in all measures of the tests. It is a simple and effective tool to use. Synoptic cytology reporting is therefore recommended for all endocrine surgical units.