Near-total Thyroidectomy Research Articles

Thyroid reoperation using intraoperative neuromonitoring

PurposeThyroid reoperations are at a high risk of recurrent laryngeal nerve (RLN) injury. The aim of the study was to investigate whether the use of intraoperative neuromonitoring (IONM) can aid in the RLN identification and minimize the risk of its injury, in comparison with visual RLN identification.MethodsThis was a retrospective cohort study of patients who underwent thyroid reoperations with and without the use of IONM. Primary endpoint was the RLN identification rate; secondary: the prevalence of RLN injury, the frequency of total thyroidectomies, and the course of the RLN.ResultsThe study involved 61 patients undergoing thyroid reoperation among whom 24 were operated on with visual RLN identification only, while 37 procedures used IONM. In the non-monitored reoperations, 44.4% of the RLN were visually identified, as opposed to 91.6% in the IONM group (p < 0.001). Transient paresis occurred in three nerves with visualization (6.6%), and in one in IONM group 1.6% (p = 0.185). Permanent paresis occurred in the group with visualization (6.6%), as opposed to none with neuromonitoring. The extent of resection in both groups was significantly different (p = 0.043). Total, near-total thyroidectomies, Dunhill operations and subtotal thyroidectomies were performed in 71, 17, 4, and 8% in the visualization group, and in 94, 0, 3, and 3%, respectively, in the IONM group. A non-anatomical RLN course was observed in 80% of the reoperations with IONM.ConclusionsThyroid reoperation should be performed using IONM, because it allows for a significantly improved RLN identification rate and a significantly more radical resection.

Minimally Invasive Video-assisted Thyroidectomy. Experience the same working group

To demonstrate the feasibility, safety and efficacy of minimally invasive video-assisted thyroidectomy (MIVAT). Design: Retrospective Ninety six patients with thyroid nodules were selected for MIVAT if they presented nodules under 35 mm in diameter, thyroid volume below 30 ml and absence of high-risk malignant tumor, lateral cervical lymphadenopathy or prior cervical surgery. Indirect laryngoscopy was performed before and after surgery to all patients. Surgery was performed through a midline incision of 1.5 cm above the sternal notch, without carbon dioxide and with magnification endoscopy. We evaluated postoperative complications, pain after surgery, the cosmetic outcome and length of stay. Ninety patients underwent total thyroidectomy or near-total thyroidectomy. The average operative time was 54 ± 9 minutes. The average diameter of the nodule was 20 ± 6 mm. The average volume was 19 ± 6 ml. We documented six (6.2%) hyperparathyroidism and one recurrent laryngeal nerve palsy (0.96%), both transient and none of them permanent. The postoperative pain was minimal and all patients were discharged within 24 hours. Conclusion: In our experience the MIVAT is a safe and feasible technique for the treatment of thyroid disease, with clear advantages over conventional thyroidectomy in selected patients. In our experience the MIVAT is a safe and feasible technique for the treatment of thyroid disease, with clear advantages over conventional thyroidectomy in selected patients.

Clinical analysis of the factors that influence disease progression of differentiated thyroid carcinoma in children.

To investigate the factors that influence disease progression of paediatric patients with differentiated thyroid carcinoma. A total of 34 patients under 18 years of age with differentiated thyroid carcinoma (32 papillary and 2 follicular; 9 males and 25 females; 19 cases younger than 15 years old and 15 cases 15-18 years old) treated in our department from June 2009 to August 2015 were retrospectively reviewed. All of the patients underwent a total thyroidectomy or near-total thyroidectomy, central node dissection and/or lateral neck dissection, radioactive iodine treatment and thyroid-stimulating hormone suppressive therapy. A univariate analysis was conducted by log-rank to evaluate the factors that influenced progression-free survival of differentiated thyroid carcinoma in these patients. The median progression-free survival time of all patients was 23 months, ranging from 4 to 72 months. Progression of pulmonary metastatic disease was observed in two cases, a recurrence in the thyroid bed was found in one case, and thyroglobulin significantly increased in four cases. In the univariate analysis, the factor that influenced progression-free survival of differentiated thyroid carcinoma was multifocality (P = 0.040), and independently, age, gender, tumour size, pathological type, degree of infiltration, lymph node metastasis and pulmonary metastasis had no significant influence on progression-free survival (P > 0.05). Multifocality was the factor that influenced the progression-free survival of differentiated thyroid carcinoma patients under 18 years of age.

Related factors analysis for lymph node metastasis in papillary thyroid carcinoma: a series of 2 073 patients

Objective: To investigate the related factors for lymph node metastasis (LNM), especially for high volume LNM (>5 metastatic lymph nodes) in papillary thyroid carcinoma (PTC). Methods: The medical records of 2 073 consecutive PTC patients who underwent lobectomy, near-total thyroidectomy or total thyroidectomy with ipsilateral or bilateral central lymph node dissection in Department of General Surgery, Peking Union Medical College Hospital from November 2013 to October 2014 were reviewed. Clinical and pathological features were collected. Univariate and multivariate analysis were performed to identify the related factors for LNM/high volume LNM. Results: In all 2 073 patients, LNM and high volume LNM were confirmed in 936 (45.15%) cases and 254 (12.25%) cases respectively. In univariate analysis, large tumor size, young patients (<40 years), male were associated with both LNM and high volume LNM. In multivariate analysis, tumor size >2.0 cm, young patients (<40 years), male were independent related factors of LNM (OR=5.262, 95% CI: 3.468 to 7.986; OR=2.447, 95% CI: 2.000 to 2.995; OR=1.988, 95% CI: 1.593 to 2.480, respectively, all P=0.000) and high volume LNM (OR=6.687, 95% CI: 4.477 to 9.986; OR=2.975, 95% CI: 2.224 to 3.980; OR=2.354, 95% CI: 1.737 to 3.191, respectively, all P=0.000). In 1 414 PTMC patients, a similar result was also demonstrated.Compared with young patients (<40 years), old patients (≥60 years) had lower incidence of LNM (25.47% vs. 52.24%, χ(2)=62.903, P=0.000) and high volume LNM (1.89% vs. 13.18%, χ(2)=37.341, P=0.000). Additionally, old patients also had lower risk of both LNM (OR=0.316, 95% CI: 0.194 to 0.517, P=0.000) and high volume LNM (OR=0.142, 95% CI: 0.034 to 0.599, P=0.000). Conclusions: The tumor size was the main related factor for both LNM and high volume LNM in PTC. The treatment should be more active in patients with tumor size >2 cm with consideration of higher incidence and risk for LNM and high volume LNM. Young patient was another important related factor for LNM and high volume LNM. In PTMC, old patients had lower incidence and risk for both LNM and high volume LNM. Dynamic observation or less surgical extent could be an option for these patients.

Quantitative thyroglobulin response to radioactive iodine treatment in predicting radioactive iodine-refractory thyroid cancer with pulmonary metastasis

ObjectiveCurrent diagnosis of radioactive iodine (RAI)-refractory (RAIR) differentiated thyroid cancer (DTC) is based on the imaging technique, which is of a high cost. Serum thyroglobulin (Tg) is a sensitive and easily obtained biomarker. Hence, we aimed to assess the predicting value of quantitative response of Tg in earlier identifying the RAIR-DTC with pulmonary metastasis.Patients and methodsPulmonary metastatic DTC patients who underwent total or near-total thyroidectomy and at least two times of RAI therapy were included in this study. The pre-ablative stimulated Tg at the first and second RAI therapy were defined as pstim-Tg1 and pstim-Tg2, while the suppressed Tg before and after the second RAI therapy were designated sup-Tg1 and sup-Tg2. The predicted value of pstim-Tg2/Tg1 and sup-Tg2/Tg1 ratio were detected using the receiver operating characteristic (ROC) curve and logistic regression analyses.ResultsTotally 115 patients were involved in this study. ROC curves showed a cut-off value of 0.544 for pstim-Tg2/ pstim-Tg1 in detecting RAIR, with a sensitivity of 0.9 and specificity of 0.477, and an area under the curve (AUC) of 0.744. Similarly, the cut-off of sup-Tg2/ sup-Tg1 was 0.972, with a sensitivity of 0.733 and specificity of 0.935, and AUC of 0.898. Univariate analysis illustrated that age, tumor size, pstim-Tg2/Tg1, sup-Tg2/ sup-Tg1 and BRAFV600E mutation were eligible to predict RAIR. While from multivariate analysis, only age, pstim-Tg2/Tg1, sup-Tg2/ sup-Tg1 and BRAFV600E mutation were verified to be the independent predictive factors.ConclusionThe quantitative Tg response was encouraging in identifying RAIR-DTC with pulmonary metastasis. Age, BRAFV600E mutation and Tg response were independent predictors in predicting RAIR-DTC.

Chinese Data of Efficacy of Low- and High-Dose Iodine-131 for the Ablation of Thyroid Remnant.

Chinese data on the efficacy of low- and high-dose radioiodine for thyroid remnant are still absent. The aim of the study was to investigate whether a low dose of radioiodine is as effective as a high dose for remnant ablation in Chinese patients. Patients presenting for radioiodine ablation in the authors' department were included. Inclusion criteria were aged ≥16 years, total or near-total thyroidectomy, tumor-node-metastasis (TNM) stage of pT1-3, any N stage, and M0. All patients were randomly allocated to either the high-dose group of 3700 MBq or the low-dose group of 1850 MBq for remnant ablation. The response to treatment was defined as successful or unsuccessful after a six- to nine-month interval. Ablation was considered to be successful if patients fulfilled the following criteria: no tracer uptake in the thyroid bed on diagnosis whole-body scanning and a negative level of serum thyroglobulin. There were 327 patients enrolled between January 2013 and December 2014. More than 95% had papillary thyroid cancer. Data could be analyzed for 278 cases (Mage = 44 years; 71.6% women), 155 in the low-dose group and 123 in the high-dose group. The rate of initial successful ablation was 84.2% in all patients, 82.6% in the low-dose group, and 86.2% in the high-dose group. There was no difference between the two groups (p = 0.509). In Chinese patients with differentiated thyroid carcinoma, the low dose of 1850 MBq radioiodine activity is as effective as a high dose of 3700 MBq for thyroid remnant ablation.

Endocrine Complications of Surgical Treatment of Thyroid Cancer: An Update.

Postoperative hypoparathyroidism (HypoPT) and hypothyroidism (HypoT) are the main endocrine complications after the surgical treatment for thyroid cancer. Postsurgical HypoPT can be transient, protracted or permanent. Its frequency varies according to the underlying cervical pathology, surgical technique, and mainly the experience of the surgeon. Risk factors for HypoPT include aggressiveness of the tumor, extent of surgery, the presence of parathyroid gland in the pathologic specimen, and surgeon experience. Clinical manifestations of postsurgical HypoPT can be acute or chronic. An adequate surgical technique that minimizes trauma and preserve the vascularization of the parathyroid glands is the better procedure to reduce the risk of postoperative HypoPT. Acute hypocalcemia may be managed with intravenous or oral calcium supplements, according to the level of serum calcium and the presence of signs and symptoms. Patients with permanent HypoPT require lifelong calcium and vitamin D supplementation. Calcitriol is the vitamin D metabolite of preference because of its high activity and short half-life. Both PTH (1-34) and intact PTH (1-84) have demonstrated to be attractive options in hypoparathyroid patients who cannot maintain stable serum and urinary calcium levels with calcium and vitamin D supplementation. However, the long-term safety of these preparations has not been established. Postsurgical HypoT is an unavoidable consequence of total or near-total thyroidectomy for thyroid cancer. Replacement and suppressive therapy are necessary in these patients. Thyroid hormone suppression therapy has shown to be accompanied by a decreased risk of disease progression and recurrence; however, it may also be associated with increased risk of dysrhythmia and loss of bone mass. Therefore, the intensity of TSH suppression must be established in a personalized way after balancing risk and benefits, according to the severity of the thyroid cancer, the response to therapy, and the individual risk factors for adverse events.

Pathological findings in 377 patients with differentiated thyroid cancer in a single centre

The purpose of this study is to review the pathology findings of 377 patients diagnosed with differentiated thyroid cancer (DTC) in a single centre over a period of six years. Retrospective review of all total and near-total thyroidectomies (TT and NTT) performed in a single institution. Clinical records were accessed for patient demographic data and clinical characteristics. Patients with a histopathologic diagnosis of DTC were grouped in incidental DTC and non-incidental DTC groups and TNM staging was used. 1465 thyroidectomies were included. The M:F ratio was 1:2.9. 377/1465 patients had a histologic diagnosis of DTC (26%). T1b group (n=227) had a statistically significant higher number of cases, where tumor invaded the capsule, tumor extending extrathyroidally, tumor invading the blood vessels compared to T1a group (n=64) (p=0.001 for all three variables). T1a group had a statistically significant higher number of papillary conventional variant of DTC and more unifocal tumors (p=0.045 and p=0.004 respectively). In the non-incidental DTC group (n=79), there were 29 patients (37%) in T1a category and 16 of them had a unifocal papillary DTC. 16/79 of patients (20%) operated for DTC had a subcetrimetric, unifocal papillary DTC. According to the 2106 American Thyroid Association (ATA) Management Guidelines, these patients could potentially have been treated with a lobectomy alone. Patients in T1b category present more aggressive histologic features and should undergo multi-disciplinary team discussion to decide optimal surgical treatment.

Aggressiveness of the tall cell variant of papillary thyroid carcinoma is independent of the tumor size and patient age.

The tall cell variant (TCV) of papillary thyroid carcinoma (PTC) is characterized by tall columnar cells with a height of at least three times their width. TCV usually presents at an older age, has a larger size and exhibits more extrathyroidal extension and metastases than classical PTC. The current study compared TCV with the classical and follicular variants (CaFVs) of PTC to determine if, irrespective of the age at diagnosis and tumor size, TCV is more aggressive than its classical and follicular counterparts. A total of 16 (3.66%) patients with TCV were identified in a series of 437 patients with PTC from the Clinical University Hospital (Santiago de Compostela, Spain) between 1990 and 2010. The patient clinicopathological features and B-Raf proto-oncogene (BRAF)V600E mutational status were compared with 34 cases of CaFVs of PTC matched for tumor size and patient age. The TCV series included 11 females and 5 males aged 15–74 years (median, 57 years). In total, 15 (93.8%) patients underwent total or near-total thyroidectomy, 1 underwent lobectomy and 5 (31.3%) underwent lymph node dissection. In the TCV series, the tumor size ranged from 5–45 mm (median, 19 mm). Compared with the CaFVs, the TCV of PTC exhibited a significantly higher prevalence of extrathyroidal extension [9/16 (56.3%) vs. 5/34 (14.7%) cases; P=0.007], lymph node metastases [9/16 (56.3%) vs. 9/34 (26.4%) cases; P=0.04], stage III/IV at presentation [10/16 (62.5%) vs. 7/34 (20.5%) cases; P=0.009] and BRAFV600E mutation [12/16 (80.0%) vs. 7/25 (28.0%) cases; P=0.004]. The TCV series also harbored more multifocal papillary carcinomas (50.0% vs. 26.4%), lymphovascular invasion (37.5% vs. 29.4%) and distant metastases (6.2% vs. 0.0%), as compared with the matched patient cohort. In conclusion, the TCV of PTC is frequently associated with BRAFV600E mutation and is more aggressive than the CaFVs of PTC, regardless of tumor size and patient age at diagnosis.

The clinical characteristics and treatment strategies of differentiated thyroid carcinoma in adolescents and children

Objective:To study the clinical characteristics and treatment strategies of differentiated thyroid carcinoma in adolescents and children.Method:From 1983 to 2014, total 2936 patients with the thyroid cancer were collected in our hospital, among which there were 85 patients of adolescents and children with 61 female and 24 male. The age was from 9 to 21 years old (median 18.3 years). There were 12 cases less than 14 years.The pathologic diagnoses were papillary carcinoma 76 cases and follicular carcinoma 9 cases. The clinical material, history of disease, clinical presentation, TNM classification, histopathological features, treatment method, and the final follow-up results were analyzed and studied. Result:Overall survival rate was 100%, follow-up from 0.5 to 31 years(medium 10.9 years), 10 year progression free survival rate was 87.1%. There was no mortality and 8(9.4%)cases occurred recurrence,who followed by surgery and resumed finally. There were 20 cases found extrathyroid extention, including 8 cases less than 14 years and 12 cases older than 15 years. The extrathyroid extention rate was significantly higher in cases of lower years(66.7%)than other group(16.4%)(P<0.01). Forty-nine(57.6%) cases were found lymphanods metastases, among them ≤14 years metastases rate 92.0%（11/12）significantly more than ≥15 years metastases rate 52.1%(38/73) (P<0.05). Three patients suffered with pulmonary metastases and all of them were ≤14 years patients. All of 85 patients were received surgery treatment included total, subtotal and oneside thyroidectomy. The neck lymph nodes were underwent modefied, radical or no neck dissection. Fifteen patients were received 131I therapy postoperatively, the dosage was 50～170 mCi. All of 85 patients were received TSH suppression therapy. 13 cases(15.3%) occurred complications,such as laryngeal recurrent nerve paralysis and hypoparathyroidism commonly. Conclusion:Majority of thyroid cancer for adolescents and children are papillary and follicular carcinoma. The histopathologic feature has significant invasion beyond thyroid capsula, and metastasis to the lymphanods and distante area,especially ≤14 years patients significant more than ≥15 years. The prognosis is favorable, it is few death from thyroid cancer. The treatment means is surgery to resect all of the disease, sometimes should perform total or neartotal thyroidectomy if there are distant metastasis and extensive invasion. It should pay attention to preserve the function of recurrent laryngeal nerve and parathyroid gland. Most of them can be performed unilateral lobectomy if the tumor located oneside thyroid gland. The lymphanode metastasis should be undertaken modified neck dissection, make effort to avoid radical neck dissection. It should be carful to use 131I internal radiation therapy and avoid the excessive treatment.

The Prevalence of Incidental Thyroid Carcinoma in Patients Who Underwent Thyroidectomy for Multinodular Goiter

The incidence of an incidental carcinoma following surgical treatment for MNG varies from 3 to 16%. The aims of this study are to determine the incidence of an incidental thyroid carcinoma (ITC) in patients with multinodular goiter (MNG) and to evaluate the primary surgical treatment modality for these patients. Between January 2010 and July 2015, a total of 3311 patients who underwent surgery for goiter were retrospectively evaluated. Demographic characteristics of the patients, previous medical history, thyroid hormone profiles, thyroid ultrasonography findings, fine-needle aspiration biopsy (FNAB) findings, thyroid scintigraphy findings, surgical techniques, early postoperative complications, and histopathological diagnoses were recorded. The patients were divided into two groups: those who were incidentially diagnosed with a thyroid carcinoma (ITC group; n = ?) and those with MNG (MNG group; n = ?). Of 3311 patients, FNAB was performed in 1524 (46%) patients. Of these, 1790 underwent total thyroidectomy (TT) or near total thyroidectomy (NTT), 1066 underwent bilateral subtotal thyroidectomy (BSTT), 354 underwent the Dunhill procedure, and 101 underwent unilateral lobectomy (ULL) due to the presence of unilateral MNG. Postoperative histopathological examinations revealed an incidental thyroid carcinoma (ITC) in 283 (8.54%) patients, papillary carcinoma in 201 patients (201/3311, 6%), follicular cancer in 68 patients (68/3311, 2%), medullary cancer in 13 patients (13/3311, 0.3%), follicular carcinoma in four patients (4/923, 0.4%), and anaplastic cancer in one patient (1/3311, 0.03%). Our study results suggest that TT should be the primary surgical treatment modality to avoid the complications of a complementary thyroidectomy.

English

BACK GROUND: Thyroidectomy is a common surgery with an extremely low mortality, with specific morbidities which are related to the experience of the surgeon. Very low morbidity rates with specialised centers. Thyroid surgery is associated with few complications and no fatality. Post-operative complications may be as insignificant as edema of the flap or as dangerous and life threatening as hemorrhage or respiratory obstruction. Complications are less with sound surgical technique and good preoperative preparation. OBJECTIVES: 1. The objective of the study is to compare complication rates of Bilateral sub total thyroidectomy (SBT), near total thyroidectomy (NTT) Hemithyroidectomy (Total lobectomy and isthmusectomy), and Total thyroidectomy (TT) in cohort of patients undergoing surgery for various thyroid disorders. 2. To compare complication rates after thyroidectomy for benign diseases and malignant diseases. 3. To identify ways to avoid the post operative complications. METHODOLOGY: It is a prospective study conducted from September 2016 to August 2017 in one hundred patients who underwent thyroidectomy surgery in our hospital which includes ninety three female and seven male patients. All basic investigation along with vocal cord examination and special investigation like thyroid profile and serum calcium is done in all patients in the study group. Meticulous pre operative preparation is done in all cases. FNAC is done in all cases of goitre under study group. Finally the outcome of various thyriodectomy procedures and their post operative complications along with nature of histopathological reports were compared. The morbidity and mortality associated with each procedure and nature of the disease were compared in this study. RESULTS: In our study flap edema occurred more frequently, that too more frequent after total thyroidectomy (12%). Seroma occurred in eight cases (8 %) but subsided rapidly. The incidence of recurrent laryngeal nerve (vocal cord) palsy is 7 % and superior laryngeal nerve palsy in four patients (4%). These complications were transient. Recovered spontaneously over the time. Post operative hypo parathyroidism occurred in four patients who underwent total thyroidectomy for malignant thyroid disorders. These incidence is due to surgical clearance for malignant disease. This study also reveals complication rates were more for total thyroidectomy than any other procedures. Incidences of other complications are also higher in bilateral total thyroidectomy. Thyroid storm, oesophageal injury and death were nil in our study group. This study revealed that the hemithyroidectomy is an extremely safe procedure without any complication. CONCLUSION: The following conclusions are drawn from this study: 1. This study shows that the total thyroidectomy or hemithyroidectomy can be done with very low complication rate in cases of benign thyroid disease affecting the whole gland. 2. Recurrent laryngeal nerve palsy , hypo parathyroidism induced hypocalcemia were occuring in total thyroidectomy procuredes in malignant thyroid disorder patients than benign disorders. 3. Thyroid carcinoma, recurrent goiter, toxic goiter and total thyroidectomy are risk factors for post operative complication. 4. There is a risk of recurrence with bilateral subtotal thyroidectomy. Because total thyroidectomy carries a risk of complication similar to that for bilateral subtotal thyroidectomy, it is no logical to avoid total resections. Therefore near total or total thyroidectomy may be the operation of choice for multinodular goiter. 5. Complications and sequelae of thyroid surgery can yet be reduced by careful evaluation of the surgical and medical therapeutic options to have more precise surgical indications, a thorough knowledge of the surgical anatomy, a rigorous surgical technique, a systematic dissection of recurrent laryngeal nerve and meticulousness during the procedure. 6. I conclude that the operative skills and experience of the Surgeon and the malignant nature of the disease are the determining factors for the complications in thyroidectomy procedures.

Post-thyroidectomy permanent hypocalcemia and hypoparathyroidism: frequency and risk factors

Abstract Background: Hypoparathyroidism is the most common complication after thyroidectomy and the main reason for frequent outpatients' visits; however, there is a poor understanding of its outcomes, and no clear follow-up strategies are available. We aimed to evaluate the frequency and risk factors of post-thyroidectomy hypocalcemia hypoparathyroidism in Libyan patients. Methods: A case series study was conducted. The serum calcium and parathyroid hormone level (PTH) were measured at least 8 months post thyroidectomy. Results: 124 patients were reviewed in this study; 19 (15.3 %) were males and 105 (84.7 %) were females. 30.6 % of males and 13.7% of females developed hypocalcemia and hypoparathyroidism. Total thyroidectomy (TT) was performed in 62.9 % of all patients, while 24.2% of all patients underwent near total thyroidectomy (NTT). 12.1% of all patients underwent bilateral subtotal thyroidectomy (BST) and 1 patient underwent hemi thyroidectomy (0.8%). The risk of hypocalcemia was higher in patients with malignant thyroid disease in comparison to benign thyroids (45.8 % vs. 27% of patients). Papillary thyroid carcinoma (PTC) was the most common cause of both hypocalcemia and hypoparathyroidism (45.5% for both) followed by Graves' disease (22.2% and 14.8% for hypocalcemia and hypoparathyroidism respectively). Hypocalcemia and hypoparathyroidism were more frequent in patients who underwent TT (19.2%), as compared to patients who underwent NTT (6.6 %). Among nine patients who were operated on twice, three patients had hypocalcemia, and two of them were found to be hypoparathyroid; one case is diagnosed with Graves' disease, while the other was diagnosed as PTC. Conclusion: Total thyroidectomy, and re-operation are associated with increased prevalence of permanent hypocalcemia and hypoparathyroidism when compared to less extensive thyroid resection modes.

Thyroid Cancer in Saudi Arabia: A Histopathological and Outcome Study.

Most data on differentiated thyroid cancer (DTC) came from the Western world. We describe its salient characteristics and outcome from a Middle Eastern country. Patients and Methods. We studied all cases of TC seen during a 2-year period (2004-2005) seen at our institution. Results. A total of 600 consecutive cases of DTC with a median age at diagnosis of 39 years (5–85) and the female : male ratio of 459 : 141 (76.5% : 23.5%). The cases included classical papillary thyroid cancer (PTC) in 77%, follicular variant PTC in 13.3%, follicular thyroid cancer in 3.2%, and other rare subtypes 6.5%. Total or near-total thyroidectomy was performed in 93%, central and/or lateral neck dissection in 64.5% of cases, and radioactive iodine ablation in 82% of cases. Additional therapies were administered to 154 patients (25.7%). At a median follow-up period of 7.63 years (0.22–13.1), 318 patients (53.3%) were in excellent response, 147 (24.5%) having an indeterminate response, 55 (9.2%) biochemically incomplete, 33 (5.5%) structurally incomplete, and 27 (4.5%) unclassifiable. Twenty cases died secondary to DTC (disease-specific mortality 3.3%). Conclusions. In Saudi Arabia, DTC is common and occurs at young age and predominantly in females. Although remission is common, persistent disease is also common but disease-specific mortality is low.

Incidence and morphological features of thyroid papillary microcarcinoma in Graves’ disease

Introduction/Objective. Association of Graves? disease (GD) and thyroid cancer is reported in a wide range from 0% to 33.7%. Papillary thyroid carcinoma (PTC) is the most commonly diagnosed malignancy in GD, namely its variant ? papillary thyroid microcarcinoma (PTMC). The increasingly frequent PTMC disclose favorable biological behavior with low mortality and recurrence rates. The aim of this work is to report our experience on the frequency and morphological features of PTMC in surgically treated patients with GD. Methods. Over a period of three years, total or near-total thyroidectomy was performed in 129 patients with GD. Results. Incidental PTMC was diagnosed in 24 (18.7%) patients with GD. The mean tumor diameter was 3.03 ? 2.17 mm. The average age of patients in the GD with PTMC group was 48.50 ? 13.07 years, while in the GD without PTMC group it was 41 ? 13.12 years, and it proved to be statistically significant ( p = 0.045). Most of the PTMC were unifocal (83%), and the most common morphological features of PTMC were intraparenchymal localization (62.5%), follicular morphology (66.7%), and infiltrative growth pattern (62.5%). Extrathyroidal extension, lymphatic invasion and multifocality of PTMC were more commonly related with subcapsular localized PTMC. The presence of at least one nodule in the GD with PTMC group was 58.3%, while in the GD without PTMC group it was 26.7%, and it was statistically significant (p = 0.003). Conclusion. Our results showed a high incidence of PTMC (18.7%) in patients with GD. Clinically, the most important morphological characteristics of PTMC were related with its subcapsular localization.

A Functional Scoring System Based on Salivary Gland Scintigraphy for Evaluating Salivary Gland Dysfunction Secondary to 131I therapy in Patients with Differentiated Thyroid Carcinoma.

Radioiodine therapy with 131I (131I therapy) after total or near-total thyroidectomy has been established as an effective treatment for Differentiated Thyroid Carcinoma (DTC), but can induce dry mouth symptoms by salivary gland damage and impair the patients' quality of life. To propose a functional scoring system based on Salivary Gland Scintigraphy (SGS) findings that evaluates development of salivary gland dysfunction secondary to 131I therapy in patients with DTC. This retrospective study evaluated the records of 279 DTC patients who underwent SGS after one or more round(s) of 131I therapy, using 370 MBqof 99mTc-pertechnetate. The SGS results were assessed using a novel functional scoring system in the Parotid Glands (PGs) and Submandibular Glands (SMGs) according to visual evaluations based on a three-point uptake score, Washout Rate (%WR) score after lemon-juice stimulation, and functional score. The scores were compared among pre treatment, low-dose (<10 GBq), and high-dose (>10 GBq) groups and among pre treatment, symptom-positive, and symptom-negative groups. Risk factors for dry mouth were analyzed by univariate and multivariate logistic regression analyses. Dry mouth symptoms developed in 15.4% of the DTC patients after 131I therapy. The three-point uptake, %WR, and functional scores in both the PG and SMG were statistically significant between low-dose and high-dose groups, and between symptom-positive and symptom-negative groups. The PG/SMG functional scores were independent risk factors for dry mouth (odds ratio, 0.03 and 0.0007 respectively). SGS-based PG and SMG functional scores were effective biomarkers to objectively evaluate salivary gland dysfunction, with the high strength of association with dry mouth symptoms.

Clinical characteristics and long-term outcome of patients with differentiated carcinoma of thyroid with bone metastases: a retrospective study

Background: Bone is the second most frequent target of distant metastases in patients with differentiated thyroid cancer (DTC). However, there is a controversy regarding the longterm outcome of the breast cancer patients wtih bone metastases. This study therefore was designed with the objective of assessing the clinical characteristics related to the long-term outcome and prognosis of patients with bone metastases. Methods: We reviewed the medical records of 360 patients of differentiated thyroid cancer followed at our institute from 2007 to 2012. A total of 57 patients were found to have bone metastases, who we analyzed with regard to their basic demographic data, clinical characteristics, treatment and clinical outcomes. Results: The incidence of bone metastases from thyroid carcinoma was 15.8%. The mean age at the diagnosis of bone metastases was 47±18 years (range 16 to 80 years); 46% patients were below 40 years of age and 53.8% of the patients were above 40 years of age. 15.3% were males and 84.6% were females. Histopathologic subtypes included papillary (38%), and follicular (45.6%). Multiple bone sites were involved in 50% of the patients with 29% of the patients with single bone site involvement; and 20.8% of the patients had metastases to other body organs. All patients underwent near-total thyroidectomy followed by aggressive radioiodine therapy. Number of 131I doses received ranged from 3 to 12 with a mean of 6.6. Mean dose of 131I per patient was 48914 MBq ± 20424 (Range: 18130 - 76960). Baseline thyroglobulin (TG) level ranged from 380ng/ml to 17300ng/ml with a mean value of 2250±5644 ng/ml. 60% of the patients showed a declining trend in TG over time, whilst 23% of the patients showed a rising trend; 6.2% of the patients had normal TG/ATG (antithyroglobulin) values throughout the course of disease. 10.4% of the patients had static TG levels. 64% of the patients with bone metastases showed 5-year survival. Conclusion: Multiple bone metastases represent a frequent complication of DTC especially of follicular thyroid cancer. In our population it is more common in females and in patients above 40 years of age. Overall survival rate is very good in the patients with bone metastasis if they are managed aggressively with total thyroidectomy and repeated radioactive iodine.

Uptake and Cytotoxicity Characterization of Radioiodine in MCF-7 and SKBR3 Breast Cancer Cell Lines

Radioiodine is an effective and low-risk therapy modality in well-differentiated thyroid cancer patients post near-total thyroidectomy. Extra thyroidal tumors such as breast cancer are known to be able to uptake radioiodine. The aim of this stud y was to analyze the uptake, efflux and cytotoxicity of radioiodine for two molecular types of breast cancer cell lines . Two types of breast cancer cell lines were used in this study, MCF-7 (luminal A type) and SKBR3 (HER2 type). The HaCaT cell line was used as normal cells. Iodine -125 (I-125) was used to measured radioiodine uptake and efflux. Clonogenic assay was used to assess cytotoxicity of iodine-131 (I-131) based on the tested cell reproductive ability. The radioiodine uptake in SKBR3 cell s was found to be higher than that of MCF-7 and HaCaT cells at p <0.05. The reproductive ability of MCF-7 cells are lower than SKBR3 cells at p <0.05 . Both breast cancer cells have less reproduction ability than HaCaT cells at p <0.05 . Both types of breast cancer cells present the ability to uptake radioiodine and show a high sensitivity to radioiodine exposure. N ormal cells also demonstrate an ability to uptake radioiodine. However, they have a better tolerance to the amount of I-131 exposure. These findings could potentially lead to the use if I-131 for ablative therapy in breast cancer, similiar to its use in the treatment of thyroid cancer. Received: 4 October 2015; Revised: 14 August 2016; Accepted: 2 September 2016

Comparative analysis of radioactive iodine versus thyroidectomy for definitive treatment of Graves disease

Management of Graves disease includes antithyroid drugs, 131I therapy, or thyroidectomy. Our aim was to review our institutional experience with definitive treatments for Graves disease. This was a retrospective review of patients undergoing 131I therapy (n=295) or thyroidectomy (n=103) for Graves disease (2003-2015). Demographic, clinical, pathology, and outcome data were collected from institutional databases. 131I therapy patients were older (39.1years vs 33.4years, P=.001). There was no difference in the presence of ophthalmopathy between groups. A larger proportion of children received thyroidectomy than 131I therapy (17.1% vs 9.2%, P=.026). The success rate of the first 131I therapy dose was 81.4%. Overall success rate, including additional doses, was 90.1%. Rapid turnover of iodine correlated with 131I therapy failure (58.3% rapid turnover failure vs 14.9% non-rapid turnover failure, P<.05). All surgical patients underwent total or near-total thyroidectomy. 131I therapy complications included worsening thyrotoxicosis (1%) and deteriorating orbitopathy (0.7%). Operative complications were higher than 131I therapy complications (P<.05) but were transient. There was no worsening orbitopathy or recurrent Graves disease among surgical patients. A higher proportion of pediatric Graves disease patients underwent thyroidectomy than 131I therapy. Rapid turnover suggested more effective initial management with operation than 131I therapy. Although transient operative complications were high, 131I therapy complications included worsening of Graves orbitopathy among those with pre-existing orbitopathy.

Cost-effectiveness profile, organizational implications and patient preferences on the use of exogenous TSH therapy (Thyrogen®) vs. THW in thyroid residue ablation in Italy

BACKGROUND: Radioiodine ablation is an adjuvant procedure used to treat patients with differentiated thyroid cancer. For ablation to be successful, patients must have elevated levels of thyroid stimulating hormone (TSH). This can be achieved by withholding thyroid hormone therapy (endogenous stimulation), or by administration of recombinant human thyroid stimulating hormone (rhTSH; Thyrogen®; exogenous stimulation) to patients in the euthyroid state.AIM: To compare the estimated health benefits, cost and cost-effectiveness of TSH stimulation with and without Thyrogen® in the Italian setting.METHODS: A cost-utility analysis was undertaken to assess the impact of exogenous vs. endogenous TSH stimulation before radioiodine remnant ablation of patients with newly diagnosed, well-differentiated papillary or follicular thyroid cancer who have undergone total or near-total thyroidectomy. A Markov model was developed to simulate treatment costs and health outcomes associated with exogenous and endogenous stimulation in four distinct health states: pre-ablation, ablation, post-ablation, and well/recovery. Treatment was stratified by patients who receive high- and low-activity (30-100 mCi, respectively) in the ablation state. The Italian National Health System perspective was adopted in the base case scenario while the impact of indirect costs was explored in a sensitivity analysis. Costs and quality-adjusted life years (QALY) specific to each health state were estimated, summarized and converted into a corresponding incremental cost-effectiveness ratio (ICER).RESULTS: We calculated a cost-effectiveness ratio of 18,357.18 €/QALY gained whereas the inclusion of indirect cost and accident cost produced reductions of the ICER to € 14,609.51 and € 15,515.26 per QALY, respectively. Finally, all results in the sensitivity analysis are below the lower bound of national and international cost- effective threshold.CONCLUSION: Thyrogen® represents a cost-effective option for patients with differentiated thyroid cancer who underwent total or near-total thyroidectomy in Italy. Our findings are consistent with other cost-utility analyses.