Stepwise Limited Axillary Lymph Node Dissection Based on Lymphatic Drainage from the Breast to Decrease Breast Cancer-Related Lymphedema: A Randomized Controlled Trial.

BACKGROUND: Comprehensive axillary surgery is associated with an elevated rate of morbidity. This trial aimed to demonstrate the feasibility of axillary dissection of lymph nodes from the breast (bALND) for the purpose of limiting the extent of surgery. METHODS: Patients enrolled from two tertiary referral centers from September 2018 to September 2019 were randomly allocated to two groups: bALND and standard axillary lymph node dissection (sALND). In the bALND group, the sentinel lymph node was filled with 0.1 ml methylene blue before resection. Then, bALND based on lymphatic drainage was subsequently performed. Lymph nodes at each breast lymphatic level and lymph nodes at Berg levels were sent for separate pathological examination. Arm lymphedema, locoregional recurrence, and distant metastasis were documented. RESULTS: In the bALND group, lymphatic vessels and subsequent-echelon lymph nodes from the breast were stained blue after injection of methylene blue in 404 (89.0%, 404/454) cases, and 57.8% (228/394) of the patients harbored fewer than four metastatic nodes. With a median follow-up of 18 months, the incidence of arm lymphedema was 6.6% (26/394) in the bALND group versus 13.7% (60/438) in the sALND group (p = 0.008), while regional recurrence presented no difference between the two surgical procedures (0.76% vs 0.68%, p = 0.896). CONCLUSION: For node-positive breast cancer patients, bALND based on lymphatic drainage is a less radical axillary surgery that can eliminate morbidity without impairing cancer control.

Intraoperative Radiofrequency Ablation for Contralateral Benign Nodules in Unilateral Thyroid Cancer Patients to Relieve Anxiety.

INTRODUCTION: For unilateral papillary thyroid carcinoma (PTC) with contralateral benign nodules, optimal extent of surgery remains controversial. This retrospective cohort study was performed to evaluate the life quality of patients who underwent lobectomy alone and lobectomy with radiofrequency ablation (RFA). METHODS: From October 2014 to October 2018, unilateral PTC patients with contralateral benign nodules reported by fine-needle aspiration cytology who encountered anxiety about contralateral nodule progression underwent lobectomy for PTC and intraoperative RFA for contralateral nodules. The patients who underwent thyroid lobectomy were matched for sex, age at time of surgery, number, size, and location of primary tumors and contralateral nodules to the patients who underwent lobectomy with intraoperative RFA. Three questionnaires were used to evaluate life quality in the two groups. The complications and rate of patients who were not required to receive thyroid-stimulating hormone suppression therapy were recorded. RESULTS: One hundred forty-eight patients with 194 contralateral nodules underwent RFA in the lobectomy plus RFA group, and age- and sex-matched patients underwent thyroid lobectomy alone. The mean volume reduction ratio was 67.7% at 12 mo and 95.2% at 24 mo. After a median follow-up of 4.2 y, nine patients (6.1%) in the lobectomy plus RFA group and 17 (11.5%) in the thyroid lobectomy-alone group underwent completion thyroidectomy (P = 0.100). Patients who underwent lobectomy plus RFA had a better quality of life in terms of anxiety, physiological health, social and family aspects, and psychological and sensory features that were measured cross-sectionally at 6 mo using three instruments. CONCLUSIONS: Intraoperative RFA is effective in terms of volume reduction of contralateral nodules and improved quality of life for unilateral PTC patients with anxiety about disease progression.

Recurrent Laryngeal Nerve with Loss of Signal During Monitored Thyroidectomy: Percentage Reduction in Sum of the Amplitude of Left and Right Channel.

PURPOSE: The prognostication for the injured recurrent laryngeal nerve (RLN) with incomplete loss of signal (LOS) and its function outcome have not been well unified. A warning criterion was proposed to predict RLN injury during monitored thyroidectomy. METHODS: A retrospective review of prospectively collected data from consecutive 357 patients with 560 nerves at risk was conducted. Vocal cords mobility with laryngoscope was performed preoperatively, on the second day, and once a month postoperatively until complete recovery. Different cutoff values of the percentage reduction in sum of the amplitude of left and right channel at the end of the surgery, for postoperative vocal cord paralysis (VCP) prediction were compared. RESULTS: Percentage reduction in sum of the amplitude of left and right channel at the end of operation ranged from 30.2 to 63.6% in 27 nerves with incomplete LOS (absolute amplitude value of final R2 > 100 µV with reduction > 50% of R1). Seven (1.25%) nerves experienced transient postoperative VCP, in which one nerve with postoperative VCP showed no amplitude reduction. The positive predictive value of VCP for the sum amplitude reduction exceeding 30, 40, 50, and 60% was 22.2, 40, 85.7, and 100%, respectively. Accuracy was 96.1, 98.2, 99.6, 99.4%, respectively. CONCLUSION: Percentage reduction in sum of the amplitude of left and right channel is a meaningful method to improve the accuracy of VCP prediction. When the sum amplitude reduction ≥ 50%, surgeons should consider the possibility of postoperative VCP and correct some surgical maneuvers.

A seven-autophagy-related gene signature for predicting the prognosis of differentiated thyroid carcinoma.

BACKGROUND: Numerous studies have implicated autophagy in the pathogenesis of thyroid carcinoma. This investigation aimed to establish an autophagy-related gene model and nomogram that can help predict the overall survival (OS) of patients with differentiated thyroid carcinoma (DTHCA). METHODS: Clinical characteristics and RNA-seq expression data from TCGA (The Cancer Genome Atlas) were used in the study. We also downloaded autophagy-related genes (ARGs) from the Gene Set Enrichment Analysis website and the Human Autophagy Database. First, we assigned patients into training and testing groups. R software was applied to identify differentially expressed ARGs for further construction of a protein-protein interaction (PPI) network for gene functional analyses. A risk score-based prognostic risk model was subsequently developed using univariate Cox regression and LASSO-penalized Cox regression analyses. The model's performance was verified using Kaplan-Meier (KM) survival analysis and ROC curve. Finally, a nomogram was constructed for clinical application in evaluating the patients with DTHCA. Finally, a 7-gene prognostic risk model was developed based on gene set enrichment analysis. RESULTS: Overall, we identified 54 differentially expressed ARGs in patients with DTHCA. A new gene risk model based on 7-ARGs (CDKN2A, FGF7, CTSB, HAP1, DAPK2, DNAJB1, and ITPR1) was developed in the training group and validated in the testing group. The predictive accuracy of the model was reflected by the area under the ROC curve (AUC) values. Univariate and multivariate Cox regression analysis indicated that the model could independently predict the prognosis of patients with THCA. The constrained nomogram derived from the risk score and age also showed high prediction accuracy. CONCLUSIONS: Here, we developed a 7-ARG prognostic risk model and nomogram for differentiated thyroid carcinoma patients that can guide clinical decisions and individualized therapy.

Development and Validation of an Intraoperative Nomogram to Predict Breast Cancer-Related Lymphedema Based on the Arm Lymphatics Distribution.

BACKGROUND: Preoperatively determining those patients who are at high risk of encountering breast cancer-related lymphedema (BCRL) is still not well understood. OBJECTIVE: This study aimed to develop a simple intraoperative nomogram for BCRL, incorporating a protective factor. METHODS: Overall, 320 breast cancer patients at Zhongnan Hospital (training set) and 221 patients at Dongfeng General Hospital (external validation cohort) treated between November 2017 and December 2018 were included. Prior to axillary lymph node dissection (ALND), 1 mL (2.5 mg) of indocyanine green was administered to the area of the internal bicipital sulcus of the upper limb. The fluorescence image was obtained and the proportion of arm lymph flow above the level of the axillary vein was calculated. Multivariate logistic regression was performed using this proportion together with clinical data. A nomogram was then constructed and assessed for its discrimination and calibration ability and clinical utility in the training and external validation sets. RESULTS: The cumulative incidence of BCRL was 18.7% (60/320), with a median follow-up of 29 months (20-34). In the multivariate logistic regression analysis, body mass index, taxane, radiotherapy, and proportion of arm lymph flow above the level of the axillary vein were identified as independent risk factors. In the training and validation cohorts, the calibration curve performed well (p = 0.721 and p = 0.315, respectively), and the area under the receiver operating characteristic curve values were 0.829 (95% confidence interval [CI] 0.773-0.885) and 0.804 (95% CI 0.732-0.877), respectively. CONCLUSION: High-risk patients could be identified intraoperatively with this nomogram, and timely intervention could be performed with preservation of the arm lymphatics.

Minimize the extent and morbidity of axillary dissection for node-positive breast cancer patients: implementation of axillary lymph node dissection based on breast lymphatics level.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is associated with extensive axillary dissection. Axillary lymph node dissection (ALND) based on breast lymphatics level (BLL) was proposed to minimize the surgical extent for node-positive breast cancer patients. METHODS: A total of 156 consecutive sentinel lymph node-positive (SLN+) or clinically node-positive (cN+) patients underwent sentinel lymph node biopsy (SLNB) with indocyanine green and methylene blue (MB). The SLNs were injected with 0.1 ml MB before removal, and a standard ALND was subsequently performed. The nodes adjacent to the blue-stained axillary lymph nodes from the breast (bALNs) were sent for pathological examination separately by resecting serial tissue every 0.5 cm away from the marginal blue-stained bALNs. Then, a pilot study comparing ALND based on BLL and standard ALND was performed. RESULTS: BLL were successfully identified in 20 SLN+ (100%) and 134 cN+ (98.5%) patients. The median number of BLL was four, ranging from three to six. A horizontal line 1.0 cm away from the superior blue-stained bALN and a vertical line 1.0 cm away from the medial blue-stained bALN formed BLL II, III, and IV. All of the additional positive nodes were within 1.0 cm of the blue-stained bALNs. The minimized axillary dissection should resect upwards from the lowest BLL that contains the first confirmed negative blue-stained bALNs. In the pilot study, no patient developed axillary recurrence. CONCLUSION: The ALND surgical procedure based on BLL could minimize the surgical extent for pathological node-positive breast cancer patients and potentially reduce the BCRL rate. TRIAL REGISTRATION: ChiCTR1800014247 .

Overexpression of CCNE1 confers a poorer prognosis in triple-negative breast cancer identified by bioinformatic analysis.

BACKGROUND: Triple-negative breast cancer (TNBC) is a major subtype of breast cancer. Due to the lack of effective therapeutic targets, the prognosis is poor. In order to find an effective target, despite many efforts, the molecular mechanisms of TNBC are still not well understood which remain to be a profound clinical challenge. METHODS: To identify the candidate genes in the carcinogenesis and progression of TNBC, microarray datasets GSE36693 and GSE65216 were downloaded from the Gene Expression Omnibus (GEO) database. The differentially expressed genes (DEGs) were identified, and functional and pathway enrichment analyses were performed using the Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) databases via DAVID. We constructed the protein-protein interaction network (PPI) and performed the module analysis using STRING and Cytoscape. Then, we reanalyzed the selected DEG genes, and the survival analysis was performed using cBioportal. RESULTS: A total of 140 DEGs were identified, consisting of 69 upregulated genes and 71 downregulated genes. Three hub genes were upregulated among the selected genes from PPI, and biological process analysis uncovered the fact that these genes were mainly enriched in p53 pathway and the pathways in cancer. Survival analysis showed that only CCNE1 may be involved in the carcinogenesis, invasion, or recurrence of TNBC. The expression levels of CCNE1 were significantly higher in TNBC cells than non-TNBC cells that were detected by qRT-PCR (P < 0.05). CONCLUSION: CCNE1 could confer a poorer prognosis in TNBC identified by bioinformatic analysis and plays key roles in the progression of TNBC which may contribute potential targets for the diagnosis, treatment, and prognosis assessment of TNBC.

Selective vagus-recurrent laryngeal nerve anastomosis in thyroidectomy with cancer invasion or iatrogenic transection.

PURPOSE: Immediate recurrent laryngeal nerve (RLN) reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function. This study is to present our experience with the methods of RLN reconstruction, and to evaluate the role of selective vagus to RLN anastomosis (SVR) in thyroidectomy. METHODS: Respective review of RLN reconstruction in thyroid surgery from January 2004 to October 2018 was conducted in two tertiary referral academic medical centers. Immediate RLN reconstruction was performed for primary thyroidectomy patients with intraoperative nerve tumor invasion or iatrogenic transection. Laryngofiberoscopic examination, voice evaluation of maximum phonation time, and GRBAS scale were performed preoperatively, on the second day after surgery, and monthly postoperatively for the first year. RESULTS: A total of 37 patients were enrolled. Twenty-nine RLNs were resected caused by tumor-associated trauma; the other nerves were inadvertently transected. Direct anastomosis (DA) was performed in eight patients, free nerve graft (FNG) was performed in four patients, ansa cervicalis to RLN anastomosis (ARA) was performed in eight patients, and SVR was performed in 17 patients. The mean periods from the reinnervation surgery of DA, SVR, ARA, and FNG to the phonation recovery were 46 ± 19 (days), 41 ± 29 (days), 83 ± 21 (days), and 137 ± 32 (days), respectively. There were improvements in the GRBAS scale of perceptual voice quality at 1 month for DA and SVR, 2months for ARA. CONCLUSIONS: Intraoperative SVR reinnervation demonstrated voice improvement postoperatively and might be an effective treatment for thyroidectomy-related permanent unilateral vocal cord paralysis.

PP2Ac upregulates PI3K-Akt signaling and induces hepatocyte apoptosis in liver donor after brain death.

Multiple research groups have demonstrated that the outcome of patients receiving liver grafts from brain death donors (DBD) is poorer when compared with patients receiving grafts from living donors. This might be due to an increased hepatocyte apoptosis induced after brain death (BD). In this work, we found that the activity of PP2A-Akt pathway is significantly increased in clinical donor ex vivo hepatocytes after BD by iTRAQ protein quantification analysis. The same results were confirmed in animal models. A time-dependent promotion of apoptosis was also found in DBD rabbit liver, as demonstrated by the increased levels of cleaved Caspase 3 and the decreased of Bcl-2. To further investigate the roles of PP2A and Akt in regulating apoptosis of hepatocytes after BD, we cultivated human liver cell line L02 with serum deprivation and hypoxia, to simulate the ischemic and hypoxic conditions of hepatocytes in DBD. Increased apoptosis and decreased viability were observed during the time in this model. Meanwhile PP2A activity and Akt activity were respectively increased and decreased. Notably, the proportion of Akt phosphorylation at Ser473 decreased, while other known targets of PP2A (p38, JNK and ERK) were not affected in terms of protein levels or phosphorylation. These results suggested that PP2A is involved in apoptotic induction of hepatocytes after brain death by specific suppression of Akt. This discovery was further confirmed with pharmaceutical and genetic methods. Our work implied potential targets for reducing liver cell apoptosis and improving organ donor quality after BD.

Difunctionalization of Alkenes via the Visible-Light-Induced Trifluoromethylarylation/1,4-Aryl Shift/Desulfonylation Cascade Reactions.

A novel visible-light-induced trifluoromethylarylation/1,4-aryl shift/desulfonylation cascade reaction using CF3SO2Cl as CF3 source was described. The protocol provides an efficient approach for the synthesis of α-aryl-ß-trifluoromethyl amides and/or CF3-containing oxindoles as well as the isoquinolinediones under benign conditions.

Visible light-mediated oxidative quenching reaction to electron-rich epoxides: highly regioselective synthesis of α-bromo (di)ketones and mechanism study.

A novel and simple procedure was developed for the regioselective synthesis of α-bromo (di)ketones from electron-rich epoxides via visible light photoredox catalysis. Through optimization of solvent and light source, the reaction can be rapidly achieved under mild conditions. Moreover, the possible reaction mechanism was proposed and further supported by control experiments.

Phase separations in oncogenesis, tumor progressions and metastasis: a glance from hallmarks of cancer.

Liquid-liquid phase separation (LLPS) is a novel principle for interpreting precise spatiotemporal coordination in living cells through biomolecular condensate (BMC) formation via dynamic aggregation. LLPS changes individual molecules into membrane-free, droplet-like BMCs with specific functions, which coordinate various cellular activities. The formation and regulation of LLPS are closely associated with oncogenesis, tumor progressions and metastasis, the specific roles and mechanisms of LLPS in tumors still need to be further investigated at present. In this review, we comprehensively summarize the conditions of LLPS and identify mechanisms involved in abnormal LLPS in cancer processes, including tumor growth, metastasis, and angiogenesis from the perspective of cancer hallmarks. We have also reviewed the clinical applications of LLPS in oncologic areas. This systematic summary of dysregulated LLPS from the different dimensions of cancer hallmarks will build a bridge for determining its specific functions to further guide basic research, finding strategies to intervene in LLPS, and developing relevant therapeutic approaches.

Prognosis difference between HER2-low and HER2-zero breast cancer patients: a systematic review and meta-analysis.

BACKGROUND: HER2-low breast cancer (BC) is proposed to be a special population of patients with an immunohistochemistry (IHC) score of 1 + or 2 + and non-amplified in situ hybridization (ISH) results. The role and prognostic impact of HER2-low BC is still controversial. This meta-analysis aims to explore the prognostic difference between of HER2-low and HER2-zero characteristic in BC patients. METHODS: A meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and eligible studies were search in PubMed, Web of Science and EMBASE databases. Quality assessment of included studies were performed by Quality in Prognostic Studies (QUIPS) tool. Hazard ratios (HRs) and corresponding 95% confidence interval (CI) for overall survival (OS) and disease-free survival (DFS) were pooled in a meta-analysis. Furthermore, subgroup analysis, sensitivity analysis, and analysis for publication bias were conducted. RESULTS: Eighteen studies comprising a total of 93,317 patients were included for meta-analysis. BC patients with HER2-low characteristic have longer OS (HRs 0.87, 95% CI 0.81-0.93, p < 0.0001) and DFS (HRs 0.82, 95% CI 0.73-0.93, p = 0.001) compared to those with HER2-zero characteristic. Subgroup analysis indicate that the source of heterogeneity may come from the hormone receptor (HR) status group. Although, the publication bias was detected, sensitivity analysis and the trim-and-fill method analysis demonstrated the stability and reliability of the results. CONCLUSION: HER2-low BC patients have longer OS and DFS compared to HER2-zero BC patients, and its prognostic value is consistent among different HR status patients. Whether HER2-low breast cancer is an independent subtype of breast cancer is still a subject of ongoing research, and more studies are needed to fully understand the molecular and clinical features of this subtype.

Ubiquitin-Specific Peptidase 8 Modulates Cell Proliferation and Induces Cell Cycle Arrest and Apoptosis in Breast Cancer by Stabilizing Estrogen Receptor Alpha.

Breast cancer (BC) is the most common neoplastic and lethal malignancy in women. Although antiendocrine therapy is the main treatment for estrogen receptor alpha (ERα)-positive BC, the development of resistance is a major clinical complication. In this study, we aimed to explore the role of ubiquitin-specific peptidase 8 (USP8) in ERα signaling and identify potential targets for endocrine resistance. Public databases were used to analyze USP8 expression, prognosis, clinical characteristics, and immune cell infiltration. Immunohistochemistry and western blot assays were used to detect protein levels and ERα signaling. Quantitative reverse transcription-PCR was used to measure ERα target gene expression. The cell counting kit-8, wound-healing, clone formation, and Transwell assays were used to investigate the effects of USP8 depletion or inhibition on cell proliferation, migration, and invasion. An immunofluorescence assay was used for localizing USP8 and ERα, and a protein stability assay was performed for detecting the degradation of ERα protein. The cell cycle and apoptosis were assessed using flow cytometry. USP8 was highly expressed in the luminal subtype of BC and was associated with poor prognosis. The infiltration levels of many immune cells were positively correlated with USP8 expression. Depletion of USP8 dramatically decreased the ERα signaling activity and weakened the proliferation, migration, and invasion capabilities of BC cells. USP8 knockdown markedly induced apoptosis and cell cycle arrest (G0/G1). Colocalization analysis and protein stability assays indicated a probable mechanism by which USP8 regulates ERα. Our study demonstrates that USP8 might be crucial in BC development and may be considered a potential target for treating ER-positive BC malignancies in vitro.

Exploration of epithelial-mesenchymal transition-related lncRNA signature and drug sensitivity in breast cancer.

Background: Breast cancer (BRCA) has become the most diagnosed cancer worldwide for female and seriously endanger female health. The epithelial-mesenchymal transition (EMT) process is associated with metastasis and drug resistance in BRCA patients. However, the prognostic value of EMT-related lncRNA in BRCA still needs to be revealed. The aim of this study is to construct an EMT-related lncRNA (ERL) signature with accuracy predictive ability for the prognosis of BRCA patients. Methods: RNA-seq expression data and Clinical characteristics obtained from the TCGA (The Cancer Genome Atlas) were used in the study. First, we identified the EMT-related lncRNA by the Pearson correlation analysis. An EMT-related lncRNAs prognostic risk signature was constructed using univariate Cox regression and Lasso-penalized Cox regression analyses. The model's performance was validated using Kaplan-Meier (KM) survival analysis, ROC curve and C-index. Finally, a nomogram was constructed for clinical practice in evaluating the patients with BRCA and validated by calibration curve and decision curve analysis (DCA). We also evaluated the drug sensitivity of signature lncRNA and the tumor immune cell infiltration in breast cancer. Results: We constructed a 10-lncRNA risk score signature based on the lncRNAs associated with the EMT process. We could assign BRCA patients to the high- and low-risk group according to the median risk score. The prognostic risk signature showed excellent accuracy and demonstrated sufficient independence from other clinical characteristics. The immune cell infiltration analysis showed that the prognostic risk signature was related to the infiltration of the immune cell subtype. Drug sensitivity analysis proved ERLs signature could effectively predict the sensitivity of patients to common chemotherapy drugs in BRCA and provide guidance for chemotherapy drugs for high-risk and low-risk patients. Conclusion: Our ERL signature and nomogram have excellent prognostic value and could become reliable tools for clinical guidance.

Investigation of nirmatrelvir epimerization occurred in analytical sample solution by using high resolution LC-MSn, NMR, and hydrogen/deuterium exchange study.

During the related substances testing of nirmatrelvir, an unknown peak was observed and the level of the peak increased over time during the storage of the sample solution. By using a strategy including LC-PDA/UV-MSn analysis, the degradant was rapidly identified as an epimer of nirmatrelvir, a solution degradation product that is caused by the trace amount of alkaline impurities leaching from the glass HPLC vials. In addition, by using hydrogen/deuterium exchange NMR spectroscopy analysis, the epimerization position was determined to be the carbon α to the adjacent cyano group. Further investigation indicated that the occurrence of the solution degradation can be suppressed when the glass HPLC vials were replaced by plastic HPLC or mass spectrometric grade vials.

Total thyroidectomy versus hemithyroidectomy with intraoperative radiofrequency ablation for unilateral thyroid cancer with contralateral nodules: A propensity score matching study.

BACKGROUND: For unilateral papillary thyroid carcinoma (PTC) patients with contralateral benign nodules, optimal treatment decisions are made according to patient preference and the disease's pathological features. This study was performed to evaluate the efficacy and complications of hemithyroidectomy with intraoperative radiofrequency ablation (RFA) compared with total thyroidectomy. METHODS: Patients with unilateral PTC and cytologically benign contralateral nodules were enrolled from 2014 to 2018. Total thyroidectomy or hemithyroidectomy with intraoperative RFA of the contralateral nodule was offered to patients who had anxiety regarding their disease. The operation-related parameters, transient or permanent nerve injury, hypocalcemia and disease recurrence, were recorded and compared between the two groups. RESULTS: After propensity score matching, 191 patients who underwent total thyroidectomy and 224 contralateral nodules in 191 patients underwent hemithyroidectomy with intraoperative RFA (HTRFA) were included. The volume reduction ratios of the contralateral nodules were 67.7% at 12 months and 95.8% at 24 months. The total thyroidectomy group reported significantly higher hypocalcemia than HTRFA within one year (7.8% vs. 2.6%, p = 0.022). Supplemental levothyroxine was not required in 28.3% (54/191) of the patients one year after HTRFA. With a median follow-up of 4.1 years, three recurrences (1.6%) were observed in the HTRFA, and no recurrence occurred in the total thyroidectomy group (p = 0.246). CONCLUSIONS: Hemithyroidectomy for unilateral PTC and intraoperative RFA for contralateral nodules were acceptable and effective treatment approaches and did not increase the risk of complications.

Visual identification and neuromonitoring vs. no sighting the external branch of the superior laryngeal nerve in thyroid surgery: a randomized clinical trial.

To evaluate the incidence of external branch of the superior laryngeal nerve (EBSLN) injuries after thyroid surgical procedures with or without the functional and visual identification of the EBSLN before ligation at the superior thyroid pole. Patients with papillary thyroid carcinoma (PTC) enrolled from a single tertiary referral academic medical center were assigned to functional and visual identification of EBSLN group (study group) or no identification of EBSLN group (controlled group). The main outcome measures were the incidence of EBSLN injury detected by the intraoperative neuromonitoring and Voice Handicap Index-10 (VHI-10) and Impairment Index-5 (VII-5) valuation questionnaires. Postoperative complications were recorded. A total of 140 (50.4%) patients were enrolled in study group and 138 (49.6%) in controlled group. In the study group, 110 (39.3%) EBSLNs were direct visual recognized and 170 (60.7%) nerves were visually identified with the help of neuromonitoring. Three patients in the study group and two patients in the controlled group were diagnosed with vocal cord paralysis. Six (4.4%) patients in the identification group and 37 (27.2%) patients in the no identification group presented no response from the stimulation of sternothyroid-laryngeal triangle. The VII-5 scores of the study group were significantly higher than those of the controlled group at one and three months postoperatively (P = 0.024 and P = 0.034). With significant lower scores of VII-5 and VHI-10, functional and visual identification of EBSLN might be necessary during thyroid surgery to protect the structural integrity and motor activity of the nerve.

Investigation of an artificial solution degradant of linagliptin: An undesired linagliptin urea derivative generates in sample preparation of linagliptin tablet treated by sonication in acetonitrile containing diluent.

During the related substances testing method development for linagliptin tablet, an unknown peak was observed in HPLC chromatograms with a level exceeding the identification threshold. By using a strategy that combines LC-PDA/UV-MSn with mechanism-based stress studies, the unknown peak was rapidly identified as linagliptin urea, a solution degradant that is caused by the reaction between the API and hydrocyanic acid with sonication treatment to accelerate dissolution of the drug substance in sample preparation of linagliptin tablets, and hydrocyanic acid is a known impurity in HPLC grade acetonitrile and acetonitrile is used as part of diluent. The mechanism of the solution degradation chemistry was verified by stressing linagliptin API with trimethylsilyl cyanide (TMSCN, which can give off HCN slowly in the presence of water) treated with sonication in the sample preparation. Further investigation found that when the sonication treatment was replaced by vortex vibration in the process of the sample preparation, the RRT 1.28 species was decreased to below the level of the detection limit (0.02%). The structure of this impurity was further confirmed through the synthesis of the impurity and subsequent structure characterization by 1D and 2D NMR. Due to the presence of trace amount of HCN in HPLC grade acetonitrile, these types of solution degradation would likely occur in analysis of pharmaceutical finished products containing APIs with primary and secondary amine moieties drug product during sample preparations, particularly when sonication treatment is used to accelerate dissolution of drug substance from the finished drug product. In the GMP quality control laboratories, such events may trigger undesirable out-of-specification (OOS) events. Hence, the results of this paper can help to prevent these events from happening in the first place or resolve these OOS events in GMP laboratories.

Warning criterion to predict recurrent laryngeal nerve injury with percentage reduction of the amplitude of V2/R2d in neuromonitoring thyroidectomy.

OBJECTIVE: To evaluate the contribution of amplitude reduction compared vagal stimulation at the end of thyroid dissection (V2) to the most distal RLN stimulation during thyroidectomy in predicting postoperative vocal cords paralysis (VCP). METHODS: Patients with intact preoperative RLN function who underwent monitored thyroidectomy between August 2017 and April 2018 were included. We routinely tested the exposed RLN at the lowest proximal end (R2p signal) and the most distal end near the laryngeal entry point (R2d signal), and then routinely detected the vagal nerve at the horizontal plane of the inferior pole of thyroid with 2mA stimulation current. The cut-off value was calculated with Receiver Operating Characteristic curve. Rates of specificity, sensitivity, negative predictive value, positive predictive value (PPV) for V2/R2d and R2p/R2d were compared. RESULTS: Percentage reduction of the amplitude of V2/R2d ranged from 34.8% to 76.7%. Twenty-two (1.5%) nerves developed temporary VCP, in which one nerve with VCP showed no significant amplitude reduction at the end of the surgery. There was no permanent or bilateral VCP. Sensitivity, specificity, PPV, NPV, and accuracy for the amplitude reduction of V2/R2d> 60% were 95.5%, 99.8%, 99.9%, 98.2%, respectively, for R2p/R2d were 99.5%, 99.2%, 63.6%, 99.9%, 97.7%, respectively. CONCLUSION: Percentage reduction of the amplitude of V2/R2d is a reliable and practical warning criterion for RLN injury. When the amplitude reduction> 60% surgeons should consider the possibility of postoperative VCP and correct some surgical maneuvers.