Central Compartment Dissection Research Articles

A case of hyalinizing trabecular tumor of the thyroid: diagnostic significance of PAX8-GLIS3 fusion

BackgroundHyalinizing trabecular tumor (HTT) is an uncommon follicular cell-derived thyroid tumor classified as a low-risk neoplasm by the World Health Organization Classification of Tumors of Endocrine Organs, 5th edition. The PAX8-GLIS3 gene fusion is reportedly a pathognomonic genetic alteration of HTT.Case presentationA 43-year-old Japanese female was incidentally discovered to have an 8-mm, well-defined, hypoechoic mass in the left lobe of the thyroid gland by ultrasound examination. Contrast-enhanced computed tomography scan revealed a solid mass exhibiting slight homogeneous enhancement in the lower pole of the thyroid gland. The mass was diagnosed as atypia of undetermined significance by fine-needle aspiration cytology. The patient underwent left hemithyroidectomy with routine central compartment dissection. Histologic findings revealed tumor cells with elongated nuclei and intranuclear pseudoinclusions arranged with trabeculae architecture or small nests in hyalinized stroma. Weak membranous and cytoplasmic staining was found by MIB1 (Ki-67) immunostaining. The final diagnosis was HTT of the thyroid gland. Next-generation sequencing genetic analysis of a surgical specimen revealed no pathologic mutations, including BRAF, H/K/NRAS, or RET-PTC fusions. The PAX8-GLIS3 fusion was detected by RT-PCR.ConclusionsA rare case of HTT was demonstrated through imaging, cytologic, histologic and molecular investigations. PAX8-GLIS3 fusion detected by RT-PCR and Sanger sequencing was confirmed to be a genetic hallmark of HTT.

Prophylactic Central Compartment Dissection on the Long-Term Outcome of Advanced (N0-T3/T4) Papillary Thyroid Cancer

Prophylactic Central Compartment Dissection on the Long-Term Outcome of Advanced (N0-T3/T4) Papillary Thyroid Cancer

New insights into histopathological features of Warthin-like papillary thyroid carcinoma

Background. The Warthin-like variant of papillary thyroid carcinoma (WLPTC) is a rare papillary thyroid carcinoma that is considered to be a subtype of the oncocytic variant. Purpose of the study: to present the diagnostic and clinical features, the oncological and surgical management of a patient with WLPTC as well as its discussion with other relevant studies. Materials and methods. We report a case of Warthin-like papillary thyroid carcinoma in a 31-year-old woman with Hashimoto thyroiditis. Results. The patient was admitted to the hospital with the presence of a node in the thyroid gland. Thyroid ultrasound showed a 24-mm nodule with oval shape and irregular contours in the left lobe. A fine-needle aspiration biopsy was performed, and a diagnosis of papillary thyroid carcinoma was made. The patient underwent thyroidectomy, bilateral modified and central neck dissection, lymphadenectomy. Histopathological examination suggested a WLPTC coexisting with chronic thyroiditis, metastases to the lymph nodes 2, 3, 4 on the left and 6 neck compartments. The patient underwent postoperative I131 ablation therapy. Conclusions. WLPTC is a recently described variant of papillary thyroid cancer that is frequently associated with lymphocytic thyroiditis. The correct cytological and histomorphological features are of utmost importance to render the diagnosis of WLPTC for better management. A surgical and postoperative treatment is identical to that in classic differentiated thyroid cancer, having a favorable outcome due to a low recurrence rate. A surgical management should be thyroidectomy and dissection of central neck compartment as well as lateral dissection in cases of suspicions for metastases in the lymph nodes or metastases confirmed preoperatively by a fine-needle aspiration biopsy.

THU516 An Unusual Neck Mass

Abstract Disclosure: P. Rios: None. N. Kalara: None. T. Shyam: None. J. Velez: None. C. Gomez: None. S. Gra Menendez: None. Background: Parathyroid carcinoma is a rare tumor which presents with a neck mass and hypercalcemia. Non-functional parathyroid tumors account for 10% of all parathyroid carcinomas and are associated with decrease or impaired secretion of PTH, having normal calcium, being difficult to diagnose. We present a case of a patient who presented with a neck mass and normocalcemia, who was diagnosed of non-functional parathyroid tumor, were immunohistochemistry played a useful role in differentiating an unsuspected parathyroid lesion from a thyroid neoplasm. Clinical Case: 49-year-old woman presented with a 6-month history of a firm mass on the left side of her neck that was initially stable but then started to grow and was painful. On examination, she was noted to have a 5 cm firm thyroid mass with bilateral level 2 lymphadenopathy. Patient had a calcium of 9.9 mg/dL (8.6-10.3 mg/dL), normal kidney function and was euthyroid. An ultrasound of the thyroid revealed a left mass near the thyroid lobe, measuring 3.1 x 4 x 2.5 cm. Fine-needle aspiration of the mass revealed a poorly differentiated carcinoma possible originating from the thyroid. The patient underwent total thyroidectomy with central compartment dissection, bilateral neck dissection and radical resection of the tumor. Frozen section revealed malignancy highly concerning for anaplastic thyroid. Immunohistochemistry (IHC) showed that the differentiated component was positive for PTH, chromogranin, PAX8 and GATA-3, while negative for TTF-1, thyroglobulin, BRAF and p53. The higher-grade component was positive for GATA-3, p53, TTF1 (weak focal), PAX-8 (weak focal) and negative for thyroglobulin, chromogranin, PTH and BRAF which was suggestive of parathyroid tissue. The final pathology report was a differentiated parathyroid carcinoma transitioning to a high-grade carcinoma with anaplastic features, 5.6 cm in the largest dimension with invasion to thyroid tissue, skeletal muscle and angiolymphatic invasion. The tumor was a pT3N0Mn/a. Next-Generation Sequencing (NGS) of the tumor showed a high tumor mutational burden as well as high microsatellite instability being beneficial Pembrolizumab for treatment if required. IHC showed PD-L1, were Nivolumab and Pembrolizumab could work in the future if needed. Also, TP53 was detected on the NGS. She completed 32 Gy/16 fractions of adjuvant radiotherapy and continues to be on active surveillance 8 months after diagnosis without evidence of recurrence of the cancer. Conclusion: Non-functional parathyroid carcinoma is a very rare tumor that should be on the differential diagnosis in a patient with normocalcemia and neck mass. Immunohistochemistry would help in the diagnosis between thyroid or parathyroid lesion as described in this case. Presentation: Thursday, June 15, 2023

Central Compartment Involvement in T3 & T4 Papillary Thyroid Carcinoma

Background: Lymphatic metastasis in papillary thyroid cancer (PTC) is common; however, the extent of central compartment lymph nodes dissection (CCD) is controversial and requires the knowledge of pattern for central compartment (level VI) lymph nodes metastasis (CCM).
 Objective: To determine the frequency of central compartment (level VI) lymph node metastasis in T3 & T4 papillary thyroid carcinoma.
 Methods: This study was conducted in the Department of Otolaryngology-Head &Neck Surgery, BSMMU, Dhaka, from January 2019 to June 2020. A total of 31 cases of T3 & T4 PTC were selected after obtaining clearance and approval from the IRB of BSMMU; the subjects were included based on the inclusion and exclusion criteria. After taking informed written consent detailed history and examination was done. Ultrasound neck and fine-needle aspiration cytology was taken from all thyroid swelling. All patients had underwent total thyroidectomy with central compartment dissection. The data were analyzed by computer-based statistical software SPSS version 26. Results were expressed as frequency and percentage. Z proportion test was done as applicable.
 Results: In this study, mean (±SD) tumor size was 3.66 (±1.34) cm. 20 (64.52%) had T3 and 11 (35.48%) T4 PTC. 11 (35.48%) had N0, 20 (64.52%) N1a and 8 (25.81%) N1b. 20 (64.52%) had overall central compartment lymph nodes metastasis. Among T3 papillary thyroid carcinoma, 12 (60%) had overall central compartment lymph nodes metastasis, and inT4 papillary thyroid carcinoma, 8 (72.7%) had overall central compartment lymph nodes metastasis. This difference was not statistically significant.
 Conclusion: The frequency of central compartment (level VI) lymph node metastasis (CCM) is high (64.52%) in T3 & T4 papillary thyroid carcinoma. So central compartment (level VI) should be dissected in advanced (T3 & T4) papillary thyroid carcinoma.
 Bangladesh J Otorhinolaryngol 2022; 28(2): 149-156

Neck Surgery for Non-Well Differentiated Thyroid Malignancies: Variations in Strategy According to Histopathology.

Lymph node metastases in non-well differentiated thyroid cancer (non-WDTC) are common, both in the central compartment (levels VI and VII) and in the lateral neck (Levels II to V). Nodal metastases negatively affect prognosis and should be treated to maximize locoregional control while minimizing morbidity. In non-WDTC, the rate of nodal involvement is variable and depends on the histology of the tumor. For medullary thyroid carcinomas, poorly differentiated thyroid carcinomas, and anaplastic thyroid carcinomas, the high frequency of lymph node metastases makes central compartment dissection generally necessary. In mucoepidermoid carcinomas, malignant peripheral nerve sheath tumors, sarcomas, and malignant thyroid teratomas or thyroblastomas, central compartment dissection is less often necessary, as clinical lymphnode involvement is less common. We aim to summarize the medical literature and the opinions of several experts from different parts of the world on the current philosophy for managing the neck in less common types of thyroid cancer.

Current controversies in the management of neck node metastasis in differentiated thyroid cancer

The incidence of nodal metastasis is quite common in well-differentiated thyroid cancer. However, its clinical significance is generally quite minimal. The adverse pathological features need to be recognized. The debate continues over prophylactic central compartment dissection. However, it needs to be re-evaluated in terms of complications of elective procedure. The extent of lateral neck dissection is standardized from level II through level V. Recurrent nodal disease is more likely to be persistent nodal disease. Appropriate preoperative imaging is very crucial. Surgery for recurrent disease needs to be considered based on nodal prognostic factors and location of the disease. The approach of using active surveillance and continuous monitoring is reasonable, especially for recurrence below 1 cm.

Risk stratification of lateral neck recurrence for patients with pN1a papillary thyroid cancer

BackgroundLateral neck is not recommended for dissection in patients with pN1a papillary thyroid cancer (PTC), but its recurrence risk has not been well stratified. We aimed to develop a risk stratification system for lateral neck recurrence in patients with pN1a PTC.MethodsPatients with pN1a PTC who underwent thyroidectomy and unilateral central compartment dissection from 2000–2016 were enrolled. The association between number of central lymph node metastases (CLNMs) and lateral neck recurrence was comprehensively assessed using a Cox proportional hazards model with restricted cubic spline. Stratification was then performed based on CLNMs and other significant risk factors selected by multivariate analysis. Lateral neck recurrent-free survival (LRFS) rate of each stratification was estimated with Kaplan–Meier curve and comparison was performed using log-rank test.ResultsNinety-six (3.8%) lateral neck recurrences were identified during a median follow-up of 62 months among a total of 2500 admitted cases. An increasing number of CLNMs was associated with compromised LRFS for up to 6 CLNMs (P < 0.001), and CLNMs > 3 indicated significantly worse 5-year LRFS than that of CLNM ≤ 3 (90.6% vs. 98.1%, P < 0.001). When stratification with CLNMs and primary tumor size (selected by multivariate analysis, HR (95%CI) = 4.225(2.460–7.256), P < 0.001), 5-year LRFS rates of high- (CLNMs > 3 and primary tumor size > 2 cm), intermediate- (CLNMs > 3 and primary tumor size 1–2 cm) and low-risk (primary tumor size ≤ 1 cm or CLNMs ≤ 3) groups were 78.5%, 90.0% and 97.9%, respectively (P < 0.05).ConclusionsThe number of CLNMs combined with primary tumor size seems to effectively stratify lateral neck recurrence risk for patients with pN1a PTC.

High-Definition 3D Exoscope in Thyroid Surgery.

The high-definition 3D exoscope is an innovative and promising tool that was recently introduced in the clinical practice. It may be used during open surgical procedures to enhance the ability to perform precise dissection of fine structures. We describe our preliminary experience with the 3D exoscope in thyroid surgery, discussing potential advantages of this system. A high-definition 3D exoscope (3D VITOM®) mounted on the VERSACRANETM holding system (Karl Storz, Tuttlingen, Germany) was used to perform open thyroid surgery. The 3D exoscope was used in three patients without significant intra-operative delay or complications. Both thyroidectomy and central compartment dissection were performed. The 3D exoscope allows to perform precise dissection in the identification and preservation of the recurrent laryngeal nerve and the parathyroid glands. 3D exoscope-assisted thyroid surgery seems to be feasible and safe. Further studies should be encouraged to analyze potential clinical benefit in the post-operative period.

Hemithyroidectomy and ipsilateral central neck dissection for T1 low-risk papillary thyroid cancer: single-institution retrospective observational study.

The aim of this study was to report the rationale and selection criteria for hemithyroidectomy and ipsilateral central neck dissection in patients with selected papillary thyroid cancer and to report the surgical and oncological outcomes. Single-institution retrospective observational study. The clinical records of patients with a histopathological diagnosis of low-risk pT1 papillary thyroid cancer who underwent hemithyroidectomy with or without ipsilateral central neck dissection between March 2000 and April 2018 at a tertiary referral center were retrospectively reviewed. Demographic, clinical, and histopathological data were collected. During the study period, 176 patients underwent hemithyroidectomy for PTC. Thirteen patients (13/176, 7.39%) were lost to follow-up and 74 patients (74/163 45.40%) underwent completion thyroidectomy within 1 month because they were classified intermediate ATA initial risk based on definitive pathology. The final study group was composed of 89 patients, who had a median follow-up of 5.3 years. The mean follow-up was 6.3 years (range: 36-207 months). Eighty-four patients (94.38%) did not experience recurrence in the follow-up period. A total of 5/89 patients (5.62%) underwent delayed completion thyroidectomy with or without neck dissection for recurrent malignancy in the residual lobe (3/5) or regional lymph nodes (2/5). The median time from surgery to recurrence was 24.8 months (range: 6-60). The follicular variant was an independent risk factor for recurrence. Hemithyroidectomy with or without prophylactic ipsilateral central neck dissection is a valuable treatment option in selected low-risk papillary thyroid cancers and ensures a low risk of recurrence. Prophylactic ipsilateral central compartment dissection could have a role in improving cancer staging, and accurate ultrasonographic follow-up is essential to identify local recurrence.

Intraoperative MET-receptor targeted fluorescent imaging and spectroscopy for lymph node detection in papillary thyroid cancer: novel diagnostic tools for more selective central lymph node compartment dissection

PurposePatients undergoing prophylactic central compartment dissection (PCLND) for papillary thyroid cancer (PTC) are often overtreated. This study aimed to determine if molecular fluorescence-guided imaging (MFGI) and spectroscopy can be useful for detecting PTC nodal metastases (NM) and to identify negative central compartments intraoperatively.MethodsWe used a data-driven prioritization strategy based on transcriptomic profiles of 97 primary PTCs and 80 normal thyroid tissues (NTT) to identify tumor-specific antigens for a clinically available near-infrared fluorescent tracer. Protein expression of the top prioritized antigen was immunohistochemically validated with a tissue microarray containing primary PTC (n = 741) and NTT (n = 108). Staining intensity was correlated with 10-year locoregional recurrence-free survival (LRFS). A phase 1 study (NCT03470259) with EMI-137, targeting MET, was conducted to evaluate safety, optimal dosage for detecting PTC NM with MFGI, feasibility of NM detection with quantitative fiber-optic spectroscopy, and selective binding of EMI-137 for MET.ResultsMET was selected as the most promising antigen. A worse LRFS was observed in patients with positive versus negative MET staining (81.9% versus 93.2%; p = 0.02). In 19 patients, no adverse events related to EMI-137 occurred. 0.13 mg/kg EMI-137 was selected as optimal dosage for differentiating NM from normal lymph nodes using MFGI (p < 0.0001) and spectroscopy (p < 0.0001). MFGI identified 5/19 levels (26.3%) without NM. EMI-137 binds selectively to MET.ConclusionMET is overexpressed in PTC and associated with increased locoregional recurrence rates. Perioperative administration of EMI-137 is safe and facilitates NM detection using MFGI and spectroscopy, potentially reducing the number of negative PCLNDs with more than 25%.Clinical trial registration.NCT03470259.

Effects of Intraoperative Neural Tunnel in Protecting Recurrent Laryngeal Nerve: Experiences in Open, Trans Breast, and Transoral Endoscopic Thyroidectomy.

BackgroundEnergy-based devices (EBDs) increase the risks of thermal nerve injuries. This study aimed to introduce a surgical strategy of intraoperative neural tunnel protecting (INTP) for evaluating the effect in reducing the incidence of recurrent laryngeal nerve (RLN) damage in open, trans breast, and transoral endoscopic thyroidectomy.MethodsINTP strategy was introduced: a tunnel was established and protected by endoscopic gauze along the direction of the nerve. A total of 165, 94, and 200 patients with papillary thyroid carcinoma (PTC) were to use INTP in respectively open, trans breast, and transoral endoscopic thyroidectomy as the INTP group. Additionally, 150, 95, and 225 patients who received the same methods without INTP were enrolled in the control group. Ipsilateral thyroidectomy or total thyroidectomy, and central compartment dissection were performed on the enrolled patients.ResultsClinicopathologic characteristics, surgical outcomes, and surgical complications were similar between the INTP group and the control group in open, trans breast, and transoral endoscopic thyroidectomy. The incidences of electromyography (EMG) changes in the INTP group were lower as compared to the control group in trans breast endoscopic thyroidectomy (p < 0.05). The incidence of postoperative hoarse in the INTP group was lower as compared to the control group in open and transoral endoscopic thyroidectomy (p < 0.05). Postoperative calcium levels (p < 0.01) were significantly higher, and the white blood cells (p < 0.05) and C-reactive protein levels (p < 0.01) were significantly decreased in the INTP group compared with the control group in transoral endoscopic thyroidectomy.ConclusionsThis was the first instance of the INTP strategy being introduced and was found to be an effective method for protecting the RLN in open, trans breast, and transoral endoscopic thyroidectomy. Additionally, INTP helped protect other important tissues such as the parathyroid glands in transoral endoscopic thyroidectomy as well as in reducing postoperative inflammatory responses.

Factors associated with postoperative hypocalcemia following thyroidectomy in childhood.

Postoperative hypocalcemia is a frequent complication after thyroidectomy. Hypoparathyroidism may develop as transient (TtHP), with normalization within six months from surgery, or permanent (PtHP) if the patient requires replacement therapy. We analyzed factors associated with the development of postoperative hypoparathyroidism and in detail PtHP following thyroid surgery in a pediatric population. A retrospective multicenter study analyzing 326 patients was carried out. We recorded gender, age, tumor size, thyroiditis, extrathyroidal extension, lymph node dissection (central/lateral compartment, unilateral/bilateral), parathyroid autotransplantation, and histology. Additionally, calcium levels were acquired postoperatively. We analyzed pediatric patients ≤18 years who underwent thyroidectomy clustered into age groups (≤15 or>15). Patients' mean follow-up was 5.8 years (1-11 years). Postoperative hypoparathyroidism occurred in 36 (11.0%): 20 cases (6.13%) developed PtHP. Postoperative hypoparathyroidism was more frequent in younger patients (P=0.014), in larger tumors (P<0.001), in case of extrathyroidal extension (P=0.037), and in central compartment (P=0.020) and bilateral lymph node dissection (P=0.030). PtHP was more frequent in older patients (P=0.014), in case of thyroiditis (P<0.001), and extrathyroidal extension (P<0.001). Concerning the first postoperative calcium level measurement, in the postoperative hypoparathyroidism group, we registered a 8.17mg/dL value with 14% pre/postoperative decrease (ΔCa ), whereas in PtHP patient group calcium level was 7.91mg/dL with 16.7% ΔCa . The risk of postoperative hypoparathyroidism is related to younger age, tumor size, central compartment and bilateral lymph node dissection, extrathyroidal extension, and decrease in postoperative calcium levels. The risk of PtHP is related to older age, thyroiditis, extrathyroidal extension, and decrease in postoperative calcium levels.

MET Targeted Molecular Fluorescence Guided Imaging and Quantitative Spectroscopy for the Detection of Lymph Node Metastases in Papillary Thyroid Cancer

Background: Patients undergoing prophylactic central compartment dissection (CLND) for papillary thyroid cancer (PTC) are often overtreated. Molecular fluorescence-guided imaging (MFGI) and spectroscopy may be useful for the detection of PTC nodal metastases (NM) and to identify negative central compartments intraoperatively. This study aims to identify a PTC-specific antigen targeted by a clinical available near infrared fluorescent (NIRF)-tracer; associate protein overexpression of the selected antigen with locoregional recurrence rates; assess selective binding of the selected NIRF-tracer in vitro and evaluate safety and efficacy of the selected NIRF-tracer for the detection of PTC NM using MFGI and quantitative spectroscopy in humans.

Factors predicting contralateral nodal spread in papillary carcinoma of thyroid.

Lymph node metastasis (LNM) is evident in about 20-50% of cases at presentation in papillary carcinoma thyroid (PTC). There are no clear recommendations for the need and extent of lateral and central compartment dissection in PTC. A total of 83 patients who underwent total thyroidectomy and bilateral selective neck dissection for diagnosed PTC from September 2011 to October 2017 were retrospectively analyzed. Tumor site was bilobar or involving isthmus in 40 patients. Contralateral LNM was seen in 42 patients. Both radiological (median size 2.6 cm, P = 0.051) and pathological (median size 3.65 cm, P = 0.015) size of tumor, tumor involving isthmus or bilateral lobes (P = 0.006), and lymphovascular invasion (LVI) (P = 0.026) had significant correlation with contralateral LNM. Size and site of tumor, ipsilateral lateral compartment nodes involvement, and LVI status of tumor significantly increases the probability of contralateral LNM in patients of PTC.

Lymph Node Dissection for Papillary Thyroid Carcinoma.

Cervical lymph node metastasis is frequent in patients with papillary thyroid carcinoma. In addition to the extent of thyroidectomy, the need as well as the extent of concomitant lymphadenectomy has been a subject of controversy and debate. The central compartment is the most frequent site of metastasis followed by the lateral compartment although skip metastasis in the lateral compartment can occur. Papillary thyroid carcinoma can also present with cervical lymph node metastasis, while the primary tumor remains clinically undetectable. Surgical removal of clinically involved nodal metastasis should be mandatory to prevent recurrence and improve disease prognosis. However, despite a low accuracy of preoperative imaging for microscopic disease and the frequent microscopic metastasis to the central compartment, routine prophylactic neck dissection has not been shown to haveany relevance to prevent recurrence or improve disease cure. Routine or prophylactic central compartment dissection is generally not recommended unless in the presence of high-risk tumors. The potential benefit of reducing central compartment recurrence or avoiding high-risk reoperation probably outweighs the risk of inducing surgical complication including hypoparathyroidism during routine central neck dissection. Therapeutic lateral neck dissection is performed for clinically involved nodes detected by preoperative imaging confirmed by needle biopsy, while prophylactic lateral neck dissection is contraindicated. The extent of neck dissection has been de-escalated, and compartmental nodal dissection aiming at preservation of function is performed to achieve a complete surgical resection. Postoperative adjuvant radioiodine is frequently administered for patients with positive nodal metastasis (intermediate-risk group) to avoid future recurrence. Routine central neck dissection may also upstage patients with microscopic nodal metastases and increase the use of postoperative adjuvant radioiodine.

The effect of fibrin glue on the quantity of drainage after thyroidectomy: a randomized controlled pilot trial.

PurposeA seroma is a collection of exudates after surgical trauma in wound healing. Fibrin glue is used to prevent seroma by reducing the generation of exudate. However, the impact of fibrin glue on the prevention of seroma remains debatable. Therefore, we conducted a randomized controlled pilot trial to investigate the effect of the amount of fibrin glue used on the generation of exudate after thyroidectomy and the sample size of future definitive trials.MethodsBetween February and December 2020, 41 patients were enrolled; 21 patients in the low fibrin group and 20 in the high fibrin group. Stratified randomization was performed based on sex, body mass index, and thyroiditis. All patients underwent total thyroidectomy and bilateral central compartment dissection. In the low and high fibrin groups, 2 mL and 6 mL of fibrin glue were applied to patients, respectively.ResultsBoth the total drain volume and flow rate during the first 12 hours were lower in the high fibrin group than in the low fibrin group (65.0 mL vs. 47.6 mL, P = 0.008 and 2.7 mL/hr vs. 1.8 mL/hr, P = 0.002, respectively). The calculated sample size for future randomized controlled trial was 32 patients (α = 0.05, power = 0.8), and the power of this trial was 0.91 with µ1 = 2.7, µ2 = 1.8, σ = 0.9, and α = 0.05 (µ = mean, σ = standard deviation).ConclusionSix milliliters of fibrin glue could reduce total drain volume and flow rate of exudate after thyroidectomy. Therefore, applying an appropriate amount of fibrin glue after thyroidectomy may reduce postoperative seroma.

Step-by-step illustrated guide to central neck dissection.

The incidence of thyroid carcinoma has been increasing worldwide and surgery is the primary treatment. Central compartment dissection of the neck is a very delicate procedure given the risks of recurrent laryngeal nerve injury and hypoparathyroidism. This paper gives a detailed description of this surgical technique in a patient affected by papillary carcinoma of the thyroid gland, supported by highly representative iconographic materials from a tertiary department. A stepwise description is provided, along with high-quality pictures and specific tips and tricks. Although neck dissection is a well-codified procedure, the fine details of this surgical technique are not currently available and are still the prerogative of the expert surgeon. The central neck compartment contains several vulnerable structures; damage to these structures would affect patients' lives, possibly permanently. Anatomical knowledge and standardisation are needed for all surgeons, particularly new surgeons (such as residents) who cannot rely simply on experience.

Thyroidectomy for Cancer: The Surgeon and the Parathyroid Glands Sparing.

Background: The diagnosis of thyroid cancer is continuously increasing and consequently the amount of thyroidectomy. Notwithstanding the actual surgical skill, postoperative hypoparathyroidism still represents its most frequent complication. The aims of the present study are to analyze the rate of postoperative hypoparathyroidism after thyroidectomy, performed for cancer by a single first operator, without any technological aid, and to compare the data to those obtained adopting the most recent technological adjuncts developed to reduce the postoperative hypoparathyroidism. Methods: During the period 1997–2020 at the Endocrine Surgery Unit of the Department of Clinical and Experimental Medicine of the University of Florence, 1648 consecutive extracapsular thyroidectomies for cancer (401 with central compartment node dissection) were performed. The percentage of hypoparathyroidism, temporary or permanent, was recorded both in the first period (Group A) and in the second, most recent period (Group B). Total thyroidectomies were compared either with those with central compartment dissection and lobectomies. Minimally invasive procedures (MIT, MIVAT, some transoral) were also compared with conventional. Fisher’s exact and Chi-square tests were used for comparison of categorical variables. p < 0.01 was considered statistically significant. Furthermore, a literature research from PubMed® has been performed, considering the most available tools to better identify parathyroid glands during thyroidectomy, in order to reduce the postoperative hypoparathyroidism. We grouped and analyzed them by technological affinity. Results: On the 1648 thyroidectomies enrolled for the study, the histotype was differentiated in 93.93 % of cases, medullary in 4% and poorly differentiated in the remaining 2.06%. Total extracapsular thyroidectomy and lobectomy were performed respectively in 95.45% and 4.55%. We recorded a total of 318 (19.29%) cases of hypocalcemia, with permanent hypoparathyroidism in 11 (0.66%). In regard to the literature, four categories of tools to facilitate the identification of the parathyroids were identified: (a) vital dye; (b) optical devices; (c) autofluorescence of parathyroids; and (d) autofluorescence enhanced by contrast media. Postoperative hypoparathyroidism had a variable range in the different groups. Conclusions: Our data confirm that the incidence of post-surgical hypoparathyroidism is extremely low in the high volume centers. Its potential reduction adopting technological adjuncts is difficult to estimate, and their cost, together with complexity of application, do not allow immediate routine use. The trend towards increasingly unilateral surgery in thyroid carcinoma, as confirmed by our results in case of lobectomy, is expected to really contribute to a further reduction of postsurgical hypoparathyroidism.

Posterior sternocleidomastoid border approach of gasless transaxillary endoscopic thyroidectomy in patients with papillary thyroid carcinoma: comparison with sternocleidomastoid fascia approach

Objective: To examine the posterior sternocleidomastoid border approach which elevated whole sternocleidomastoid in gasless transaxillary endoscopic thyroidectomy. Methods: The clinical data of 46 patients with papillary thyroid carcinoma treated with gasless transaxillary endoscopic thyroidectomy from May 2019 to June 2020 at Department of Head and Neck Surgery, Sichuan Cancer Hospital was analyzed retrospectively. There were 9 males and 37 females, aged (38.6±12.0) years (range: 19 to 74 years). Fourteen and 32 cases performed posterior sternocleidomastoid border and sternocleidomastoid fascia approach, respectively. Comparative analysis were performed on clinical characters, surgical outcomes, postoperative complications, postoperative pain score, and quality-of-life of postoperative 1 month by t test, Wilcoxon rank sum test, Fisher exact test and χ2 test,respectively. Resuts Complete exposure of central compartment was higher (11/14 vs. 34.4%(11/32),χ²=7.624, P=0.006), more lymph nodes was retrieved (4.2±2.9 vs. 2.0±2.5, t=2.663, P=0.011) in posterior sternocleidomastoid border approach. There were no significant differences between groups in postoperative complications such as recurrent laryngeal nerve palsy (1/14 vs. 3.1%(1/32), P=0.521) and transient hypoparathyroidism (0 vs. 6.2%(2/32), P=1) and pains and quality-of-life. Conclusion: Posterior sternocleidomastoid border approach of gasless transaxillary endoscopic thyroidectomy is safe and reliable and has the advantage of central compartment dissection without increasing trauma.