Incidence and Risk Factors for Occult Level 3 Lymph Node Metastases in Papillary Thyroid Cancer.

BACKGROUND: Papillary thyroid cancer (PTC) frequently disseminates into cervical lymph nodes. Lateral node involvement is described in up to 50 % patients undergoing prophylactic lateral neck dissection. This study aimed to assess this finding and identify which factors predict for occult lateral node disease. METHODS: Patients with fine needle aspiration-confirmed PTC (Bethesda V or VI), without evidence of cervical lymph node metastases, underwent a total thyroidectomy with prophylactic ipsilateral central and level 3 dissection. Level 3 nodes were removed by compartmental dissection or by sampling the sentinel nodes overlying the jugular vein, according to surgeon preference. Data were collected prospectively from January 2011 to August 2014. Statistical analysis was performed by SPSS software. RESULTS: A total of 137 patients underwent total thyroidectomy with prophylactic ipsilateral central and level 3 dissection for PTC. The incidence of occult level 3 disease was 30 % (41/137 patients). A total of 48 % of patients (66/137) harbored occult central neck disease. A total of 80.5 % of patients with pN1b disease had macrometastases (≥2 mm), and 15 % exhibited skip metastases with central compartment sparing. In patients with pN1b disease, a median of 6 level 3 nodes were retrieved, with an average involved nodal ratio of 0.29. Multivariate regression demonstrated risk factors for occult lateral neck metastasis include tumor size (odds ratio 1.1), upper pole tumors (odds ratio 6.6), and vascular invasion (odds ratio 3.2) (p < 0.05). CONCLUSIONS: PTC is associated with a significant incidence of occult central and lateral nodal metastases. In patients undergoing prophylactic central neck dissection, inclusion of level 3 dissection should be considered in patients with large upper lobe cancers.

An initial report on the intraoperative use of indocyanine green fluorescence imaging in the surgical management of liver tumorss.

BACKGROUND: There has been a recent interest in the use of Indocyanine green (ICG) imaging. The aim of this study is to review our initial experience in liver surgery. METHODS: ICG fluorescent imaging was used in 15 patients undergoing surgical treatment of their liver tumors between 2015 and 2016. ICG imaging was initially performed, followed by intraoperative ultrasound (IOUS). Findings on fluorescence were compared with preoperative cross-sectional imaging and IOUS. RESULT: Sixty-two lesions were identified, with 34 located superficially and 28 deeply in the liver. While 13 patients underwent surgery for malignant liver metastases, two patients had operations for benign liver diseases. Seven patients underwent open or robotic liver resections, five laparoscopic microwave liver ablation, and three diagnostic laparoscopy. ICG identified all of the superficial lesions. IOUS identified 98% of all lesions. The most benefit of ICG was in showing the margins of the superficial lesions in real-time and guiding surgical treatment, which was limited by IOUS. CONCLUSION: This is the first North American study to evaluate the potential utility of ICG during liver surgery. Its major benefit seems to be in providing real-time feedback to the surgeon about the margins of superficial tumors for resection or ablation. J. Surg. Oncol. 2016;114:625-629. © 2016 Wiley Periodicals, Inc.

The utility of indocyanine green fluorescence imaging during robotic adrenalectomy.

BACKGROUND AND OBJECTIVES: Indocyanine green (ICG) has been used for medical imaging since 1950s, but has more recently become available for use in minimally invasive surgery owing to improvements in technology. This study investigates the use of ICG florescence to guide an accurate dissection by delineating the borders of adrenal tumors during robotic adrenalectomy (RA). METHODS: This prospective study compared conventional robotic view with ICG fluorescence imaging in 40 consecutive patients undergoing RA. Independent, non-blinded observers assessed how accurately ICG fluorescence delineated the borders of adrenal tumors compared to conventional robotic view. RESULTS: A total of 40 patients underwent 43 adrenalectomies. ICG imaging was superior, equivalent, or inferior to conventional robotic view in 46.5% (n = 20), 25.6% (n = 11), and 27.9% (n = 12) of the procedures. On univariate analysis, the only parameter that predicted the superiority of ICG imaging over conventional robotic view was the tumor type, with adrenocortical tumors being delineated more accurately on ICG imaging compared to conventional robotic view. CONCLUSIONS: This study demonstrates the utility of ICG to guide the dissection and removal of adrenal tumors during RA. A simple reproducible method is reported, with a detailed description of the utility based on tumor type, approach and side. J. Surg. Oncol. 2016;114:153-156. © 2016 Wiley Periodicals, Inc.

The utility of indocyanine green near infrared fluorescent imaging in the identification of parathyroid glands during surgery for primary hyperparathyroidism.

BACKGROUND AND OBJECTIVES: Intraoperative adjuncts for the localization of parathyroid glands in parathyroid surgery are limited. The aim of this study is to assess the usefulness of indocyanine green (ICG) near-infrared (NIR) fluorescent imaging in patients undergoing surgery for primary hyperparathyroidism (PHPT). METHODS: ICG imaging was performed in 33 patients undergoing parathyroidectomy (PTX). Thyroid and parathyroid ICG uptake were assessed and independently verified on a grading scale. Clinical variables were recorded and analyzed for factors associated with ICG uptake. RESULTS: Of 112 glands identified by naked eye, 104 (92.9%) demonstrated ICG uptake. Concomitant ICG fluorescence was identified in the thyroid in all patients. There was a trend toward increased ICG fluorescence in patients <60 years of age (P = 0.05). A higher degree of fluorescence was seen in patients presenting with pre-operative calcium values >11 mg/dl (P = 0.04) and in those parathyroids larger than 10 mm (P < 0.01). All patients had biochemically proven cure. No patients who underwent subtotal PTX (n = 6) developed postoperative hypoparathyroidism. CONCLUSION: ICG can reliably localize parathyroid glands during PTX and additionally allow for assessment of parathyroid perfusion in patients undergoing subtotal resection. Concomitant fluorescence of the thyroid gland limits ICG's usefulness in directing the course of PTX. J. Surg. Oncol. 2016;113:771-774. © 2016 Wiley Periodicals, Inc.

Laparoscopic microwave thermosphere ablation of malignant liver tumors: An analysis of 53 cases.

BACKGROUND AND OBJECTIVES: Microwave thermosphere ablation (MTA) is a new technology that is designed to create spherical zones of ablation using a single antenna. The aim of this study is to assess the results of MTA in a large series of patients. METHODS: This was a prospective study assessing the use of MTA in patients with malignant liver tumors. The procedures were done mostly laparoscopically and ablation zones created were assessed for completeness of tumor response, spherical geometry and recurrence on tri-phasic CT scans done on follow-up. RESULTS: There were a total of 53 patients with an average of 3 tumors measuring 1.5 cm. Ablations were performed laparoscopically in all but eight patients. Morbidity was 11.3% (n = 6), and mortality zero. On postoperative scans, there was 99.3% tumor destruction. Roundness indices A, B, and transverse were 1.1, 1.0, and 0.9, respectively. At a median follow-up of 4.5 months, incomplete ablation was seen in 1 of 149 lesions treated (0.7%) and local tumor recurrence in 1 lesion (0.7%). CONCLUSIONS: The results of this series confirm the safety and feasibility of MTA technology. The 99.3% rate of complete tumor ablation and low rate of local recurrence at short-term follow up are promising.

The feasibility of indocyanine green fluorescence imaging for identifying and assessing the perfusion of parathyroid glands during total thyroidectomy.

BACKGROUND: There are limited adjuncts available for identifying and assessing the viability of parathyroid glands (PGs) during total thyroidectomy (TT). The aim of this study is to determine the feasibility of indocyanine green (ICG) imaging in identifying and assessing perfusion of PGs during TT. METHODS: ICG was administered in patients undergoing TT and fluorescence of PGs was assessed. A grading scale was developed for assessing degree of ICG uptake. Patients were evaluated for hypocalcemia and hypoparathyroidism on post-operative day (POD) #1. RESULTS: Twenty-seven patients underwent TT with ICG imaging for multinodular goiter (n = 13), thyroid cancer (n = 10), and Graves' disease (n = 4). Eight-five PGs were identified visually, 71 (84%) of which showed ICG fluorescence. False negative rate was 6%. Post-operatively, three patients (11%) had a serum calcium value <8 mg/dl. ICG uptake after TT correlated with post-operative PTH levels: mean POD#1 PTH of those patients with at least two PGs exhibiting <30% fluorescence was 9 pg/ml; whereas those with fewer than two demonstrating <30% fluorescence had a POD#1 PTH of 19.5 pg/ml (P = 0.05). CONCLUSION: ICG imaging of PGs during TT is feasible. ICG might be a useful adjunct in identifying those patients at risk for post-thyroidectomy hypoparathyroidism. J. Surg. Oncol. 2016;113:775-778. © 2016 Wiley Periodicals, Inc.

The Weight of the Resected Gland Predicts Rate of Success After Image-Guided Focused Parathyroidectomy.

BACKGROUND: A recent study of focused minimally invasive parathyroidectomy (FPTX) in sporadic primary hyperparathyroidism (pHPT) using intraoperative parathyroid hormone (ioPTH) measurements shows that inadequate ioPTH drop and multiglandular disease are more commonly found when a first gland<200 mg is resected. Our aim was to study if a resected gland that weighed <200 mg was associated with an increased persistence rate after FPTX. METHODS: This is a cohort study of FPTX for pHPT performed in the period 1998-2013. FPTX was performed in patients with pHPT where Sestamibi and Ultrasound imaging localized single-gland disease, only one gland was excised and the weight recorded. IoPTH was not used routinely. Two groups were composed according to the weight of the resected gland: Group A<200 mg and Group B≥200 mg. Persistent or recurrent disease was defined if it occurred within, or after 6 months. The primary outcome measure was the rate of persisting pHPT. RESULTS: A total of 3,511 parathyroidectomies were performed, and a total 1,745 FPTX (1,347 female) met inclusion criteria. There were 245 and 1,500 patients in groups A and B, respectively. The rate of persistent pHPT was higher in Group A, 6.1 versus 2.0% (p<0.001). Findings at re-operative surgery showed that the ipsilateral gland was diseased in 47% (7/15) of persistent cases in group A. CONCLUSION: The risk of persistent disease after MIP was higher if the resected gland weighed ≤200 mg, and this corroborates the findings of a recent study. A heightened awareness of the possibility of multigland disease should be raised, and ioPTH monitoring, identification of the ipsilateral gland or bilateral exploration may be advisable in such cases.

Non- COVID fatalities in the COVID era: A paradigm shift in the face of a pandemic- lessons learnt (or not).

INTRODUCTION: The rapid spread of the coronavirus pandemic and the associated high morbidity and mortality led to sudden lock down, forcing the elderly and others in the high risk group into isolation. Elective health care services including diagnostics, therapeutics and elective surgical services were put on hold, leading to delays seriously affecting cancer and non-cancer related services. In spite of lessons learnt during the first wave, similar issues have persisted during the second wave, increasing the pressure on an already fragile infrastructure. METHODS: Information related to surgical patients admitted since lock down (March to August 2020) as an emergency was collected on a structured proforma and analysed. Data was gathered from prospectively kept patient admission lists and Electronic Discharge summaries. All the patients who were directly or indirectly affected with poor outcomes including delayed diagnosis and treatment were identified and included in the analysis. RESULTS: A total of 185 patients were admitted as an emergency during this period. Of these Eight patients admitted under surgical care were included in the study. Four out of eight patients were diagnosed with advanced cancer and the remainder presented with complications of benign pathologies. Of the four patients with advanced cancer, three patients had advanced colorectal and the fourth had advanced ovarian cancer. All four patients either presented late or had delayed access to investigations. Three out four patients with benign disease presented with complications due to cancellation of elective and semi urgent services. One patient who was COVID positive and presented with bowel perforation died after a prolonged hospital stay. CONCLUSION: There is definite evidence of unfavourable patient outcomes in non COVID patients as a result of the COVID pandemic. As COVID is unlikely to whither down in the very near future and highs and lows are expected, rapid and safe reintroduction of elective health care services affected by COVID is the call of the hour. In addition, more efforts should be directed towards increasing awareness amongst patients regarding the importance of reporting red flag symptoms and encouraging them to access health care services.

Clinicopathological Features and Metastatic Pattern of Triple-positive Breast Cancer Among Female Patients at a Tertiary Care Hospital.

Objectives The heterogenicity of breast cancer (BC) is determined by the status of human epidermal growth factor receptor 2 (HER2/neu), estrogen receptor (ER), and progesterone receptor (PR). Triple-positive BC (TPBC) expresses the amplification/overexpression of the HER2 pathway and is positive for ER and PR. This subtype has a distinct clinical behavior. However, very few studies are focused on TPBC. This study investigated the clinicopathological features and metastatic pattern of TPBC. Methods A seven-year retrospective study was conducted at King Abdulaziz University Hospital in Jeddah, Kingdom of Saudi Arabia. All females with TPBC diagnosed between January 1, 2010, and June 30, 2017, were enrolled. Mean and standard deviation were calculated. Results From 1205 BC patients, the TPBC incidence was 10% (n = 124). The mean age at diagnosis was 51 years. On physical examination, a high tendency to show pathological skin changes was observed. Invasive ductal carcinoma was the most common histological type, presenting with a poorly differentiated histological grade (grade 3). Over a median two-year follow-up, the incidence of metastasis was 27.4% (n = 34). Bone was the most common site. The incidence of locoregional recurrence was 9.7%. Overall survival was 89.5%. Conclusion TPBC has an early tendency for metastasis and commonly affects the breast skin. BC should be approached based on the immunohistochemical diagnosis. We encourage more comprehensive studies to target TPBC for more insights into the heterogeneity of BC.

The current status of robotic transaxillary thyroidectomy in the United States: an experience from two centers.

BACKGROUND: Few studies exist regarding the state of robotic transaxillary thyroidectomy (RT) and its outcomes at high-volume institutions. METHODS: Eighty-nine patients underwent RT between January 2009 and September 2015 at two tertiary centers. Data were collected from prospectively-maintained IRB-approved databases. Patient demographic and clinical data, and trends were evaluated. RESULTS: Indications for RT included biopsy-proven or suspicion for malignancy in 20.2%, atypical cells or follicular neoplasm in 27.7%, multinodular goiter in 26.6%, thyrotoxicosis in 8.5%, need for completion thyroidectomy in 5.3%, and non-diagnostic FNA in 3.2%. 56% underwent total thyroidectomy and 44% lobectomy. Operative time (OT) was 153.5 minutes for lobectomies and 192.6 minutes for total thyroidectomy. The complication rate was 11.7%: temporary RLN neuropraxia in 2 patients, permanent hypoparathyroidism in 1 patient, temporary hypoparathyroidism in 6 patients, flap seroma in 1 patient, and flap hematoma in 1 patient. Pathology showed malignancy in 43 patients. At a mean follow-up of 31.9 months, there were no recurrences. Since 2013, the number of RTs performed has risen. The number of out-of-state patients increased from 18% to 37% after 2011. CONCLUSIONS: RT was performed without compromising outcomes in selected patients. There remains interest among patients seeking this procedure in expert centers.

Bilateral recurrent laryngeal nerve injury in a specialized thyroid surgery unit: would routine intraoperative neuromonitoring alter outcomes?

BACKGROUND: Bilateral recurrent laryngeal nerve (RLN) palsy following total thyroidectomy is a rare complication, however, poses significant morbidity to the patient when it does occur. The purpose of this paper was to determine the incidence of bilateral RLN palsy in a specialized thyroid unit and determine whether the routine use of intraoperative nerve monitoring (IONM) would alter the outcome. METHODS: This is a retrospective review of prospectively gathered data. A total of 7406 patients underwent total thyroidectomy at the University of Sydney Endocrine Surgical Unit between January 1990 and February 2014. IONM was utilized on a selective basis and we sought to assess whether IONM would have altered outcome in those patients who developed bilateral RLN palsy. RESULTS: Of the 7406 patients who underwent total thyroidectomy, seven patients (0.09%) developed bilateral RLN palsy during the study period. There was one permanent RLN palsy (0.01%) and routine IONM may have prevented one death and altered the outcome in two of the seven patients. CONCLUSION: Bilateral RLN palsy is a rare entity occurring in one out of 1000 cases in a specialized thyroid unit. IONM may facilitate the decision to pursue delayed surgery where the signal is lost on the first surgical side and has the potential to avoid bilateral RLN palsy following total thyroidectomy.

The Covidien LigaSure Maryland Jaw Device.

Since its invention nearly 20 years ago, the Covidien LigaSure device along with its ForceTriad generator has dominated the Electrothermal Bipolar Vessel Sealing market. The LigaSure was used for surgical procedures, both open and laparoscopic. The purpose of this review is to provide evidence of the safety and utility of the LigaSure device compared to more traditional means of hemostasis and its ultrasonic competitor, particularly in laparoscopic applications. We will provide evidence related to electrothermal bipolar vessel sealing in general and look specifically at Covidien's newest product, the LigaSure Maryland Jaw Device.

Macrophages as stimulators of MART-1 27-35 epitope-specific human cytolytic T lymphocytes in vitro.

BACKGROUND: Activation and expansion of antigen-specific cytolytic T lymphocytes (CTL) require epitope presented by antigen-presenting cells (APC). Presently, dendritic cells (DC) are viewed as the most efficient APC. Since the recognition of DCs as the professional APC, the paradigm has emerged that macrophage (MPhi) are scavengers and are incapable of activating T cells. METHOD: The melanoma-associated MART-1(27-35) peptide-loaded MPhi from HLA-A2-positive donors were used to activate MART-1(27-35) epitope-specific CTL in vitro. RESULTS: We show that peptide-pulsed MPhi stimulate MART-1(27-35) epitope-specific precursors to proliferate and to express effector functions. We also show that upon restimulation with the peptide pulsed MPhi, a fraction of the epitope-specific CTLs undergoes activation-induced cell death. The activation-induced cell death is induced in an epitope-specific manner and through apoptosis. CONCLUSION: MPhi can function as APC and are also capable of modulating expansion and contraction of CTL response in vitro.