Need For Completion Thyroidectomy Research Articles

BRAF V600 co‐testing is technically feasible in conventional thyroid fine needle aspiration (FNA) cytology smears and can reduce the need for completion thyroidectomy

While fine needle aspiration cytology (FNAC) is the mainstay of diagnosis in thyroid nodules, molecular markers of thyroid cancer have recently been shown to be of value in improving the diagnosis and reducing the rates of unnecessary surgery. A technical method is presented for the assessment of the BRAF V600 gene mutation in thyroid cancer using a simple adaptation of a commercially available kit. After standard preparation and reporting of conventionally stained alcohol-fixed Papanicolaou or air-dried Giemsa-stained slides the coverslip is removed from one slide, the DNA is extracted and submitted for PCR analysis. Assessment of the BRAF V600 mutational status is feasible in very small quantities of DNA, requiring just greater than 5ng per case from a single pre-stained FNA slide using this method. From the 14 cases examined thus far, one Thy4/Bethesda Class V case (suspicious of malignancy) has been identified with a BRAF V600 mutation and this patient, after multidisciplinary discussion, received a total thyroidectomy. Based on this methodology and other published results for the BRAF mutation, we believe that it is now feasible and cost effective for the UK NHS to BRAF co-test all Thy4/Bethesda Class V thyroid FNAs, as the additional cost of BRAF testing will still be much less than the cost of submitting all Thy4 (Bethesda Class V) patients to a partial and then a later completion thyroidectomy.

Thyroid Surgical Care 2013: The Impact of Molecular Testing

Program Description: Increase the awareness and cost-effectiveness of molecular alteration testing so that clinicians can consider integrating this into their thyroid practices through didactic presentations and case studies. BRAF and RET/PTC testing through routine FNA for the indeterminate nodule are nearly 100% specific for papillary thyroid cancer and can lead to initial therapeutic thyroidectomy, reducing the need for completion thyroidectomy. Molecular classifiers have a 95% negative predictive value for indeterminate nodules and may have a broad effect on reducing unnecessary diagnostic lobectomies. BRAF positive patients may have a higher rate of central neck recurrence and poorer prognosis leading to tailored surgical management. Educational Objectives: 1) Evaluate commercially available molecular alteration testing approaches and their cost-effectiveness for diagnosis, tailored management, and prognosis for indeterminate nodules through didactic and case presentations. 2) Interpret the potential of molecular alteration testing to lead to initial therapeutically optimal thyroidectomy for indeterminate nodules potentially reducing the rate of completion thyroidectomy. 3) Recognize the potential of molecular classifier testing to reduce unnecessary diagnostic thyroid lobectomy for indeterminate nodules that are benign.

Management of Papillary Thyroid Microcarcinoma: Primum Non Nocere!

Papillary thyroid cancer is quite rare, representing nearly 1% of all human solid cancers. However, in recent years it has attracted the attention of medical societies and the media after evidence has been provided that it is the human solid cancer showing the largest worldwide rise in incidence over the previous 10–20 years. The increase is mainly due to small ( 1 cm) papillary thyroid cancers, usually referred to as papillary thyroid microcarcinomas (PTMCs), and the reason for the increase is attributed to the fortuitous discovery of subclinical thyroid nodules as a consequence of the widespread use of neck ultrasound. If this is indeed the case, it is likely that we are facing an “epidemic” of thyroid tumors that in the past would have gone undiagnosed and never have become clinically apparent. PTMCs are found in otherwise normal thyroid glands or in multinodular goiters, sometimes associated with lymph node metastases at presentation and locoregional recurrences during follow-up. Distant metastases are extremely rare but have been reported. Cancer-related deaths are unusual. Although mainly based on retrospective studies, current guidelines (1) or expert consensus (2) do not recommend aggressive treatment of PTMC, do not advocate the need for completion thyroidectomy whenever discovered fortuitously at final histology, do not advocate postsurgical radioactive thyroid ablation, and limit the follow-up to periodic neck ultrasound and measurement of serum thyroglobulin. However, from time to time a new article reports on the potential aggressiveness of PTMC and suggests treatment strategies similar to those of larger, more worrisome papillary thyroid carcinomas. This is the case with the original paper in the present issue of the JCEM by Malandrino et al (3). The authors have compared the epidemiological features of PTMC studied over a 5-year period in the Sicilian Registry for Thyroid Cancer (SRRTC) in Italy and in the Surveillance Epidemiology and End Results (SEER) registry in the United States. What they found is that the age-standardized incidence rate of thyroid cancer in general, and of PTMC in particular, was higher in Sicily (PTMC, 5.8 per 100 000 inhabitants; 52.7% of all thyroid cancers) than in the United States (2.9 per 100 000; 32.5% of all thyroid cancers). Ethnicity or environmental factors (in the SRRTC there is the confounding factor of the Catania Province, which is a volcanic areawith thehighest age-standardized incidence rate of thyroid cancer) may be suggested for this difference, although the most likely explanation may be an overdiagnosis of micronodules in Sicily and an underdiagnosis in the United States. Italy is a country of moderate iodine deficiency, and thyroid screening in the era of ultrasound is particularly implemented in the entire country and in Sicily, where several teams of tertiary level endocrinologists are operating. In both registries, more than 35% of patients with PTMC exhibited 2 or more risk factors for recurrence (42.7% in the SEER and 37.8% in the SRRTC). In the opinion of Malandrino et al (3), these patients may require surgery and follow-up similar to larger carcinomas. What are these risk factors? They are pathological features (tumor size, lymph nodes, extrathyroidal extension, and multifocality) plus young age, which surprisingly was more frequently associated with other negative risk factors. The authors have no follow-up data in their series; thus the definition of risk factors for recurrence is extrapolated from other series, mainly the series by Yu et al (4), based on an analysis of the same SEER during 1988–2007 and a French series by Buffet et al (5). The series of Yu et al (4), however, does not take recurrence into account but con-

Total Thyroidectomy for Benign Thyroid Disease

To compare the outcomes of bilateral subtotal (BST) versus total thyroidectomy (TT) for benign bilateral thyroid disease (BBTD). The extent of thyroid resection in benign goiter is controversial. Potential advantages of TT over BST may include: one-stage removal of incidental thyroid cancer, and a lower risk for goiter recurrence. However, these potential advantages should outweigh the risk of morbidity. A retrospective cohort study was conducted of 8032 patients with BBTD operated in a single institution. Patients in Group A underwent BST (1999-2004, n = 5214; follow-up 72.3 ± 12.4 months), whereas patients in Group B underwent TT (2005-2009, n = 2918; follow-up 36.3 ± 10.6 months). Data were collected prospectively. The analysis included: prevalence of incidental thyroid cancer, recurrent goiter, need for completion thyroidectomy, and morbidity. Incidental thyroid cancer was found in 406 (5.00%) patients. One hundred twelve (2.15%) BST versus 3 (0.10%) TT patients required completion thyroidectomy (P < 0.001). Recurrent goiter was diagnosed in 364 (6.99%) BST patients and 165 (45.33%) required reoperation versus 0% after TT (P < 0.001). The prevalence of transient and permanent hypoparathyroidism was 2.70% and 0.15% versus 13.12% and 0.10% (BST vs. TT, P < 0.001 and P = 0.65, respectively). The prevalence of temporary and permanent RLN injury was 2.30% and 0.71% versus 2.60% versus 0.69% (BST vs. TT, respectively; nonsignificant). Compared to TT, BST resulted in a significantly higher rate of completion thyroidectomy for incidentally diagnosed thyroid cancer and need for redo surgery for recurrent goiter. The extent of surgical resection had no significant impact on the prevalence of permanent complications. NCT01273714 (http://www.clinicaltrials.gov).

Total and Near-total Thyroidectomy is Better Than Subtotal Thyroidecomy for the Treatment of Bilateral Bening Multinodular Goiter; A Prospective Analysis

Objective: To analyze the safety and effectiveness of total thyroidectomy in the surgical management of bilateral benign multinodular goiter. Materials and Methods: A prospective review of patients with bilateral benign multinodular goiter undergoing subtotal thyroidectomy (Group 1), and near-total thyroidectomy and total thyroidectomy (Group 2) during 5-year period was undertaken. Patients' demographics, indications for surgery, type of operation performed, final histological diagnosis and complications were recorded. Transient and permanent complications regarding hypoparathyroidism and recurrent laryngeal nerve paralysis were analyzed for each surgical procedure. Results: Out of a total of 207 patients, recurrence of benign multinodular goiter was recorded in 27 (30%) cases in group 1 while there was no recurrence in group 2 (p < 0.01). Completion thyroidectomies were performed in 31 (34%) patients in group 1 whereas none was required in group 2 (p < 0.01). Incidental thyroid malignancy was found to be 18% (n= 38/207) in this study which necessitated completion thyroidectomy in group 1 patients. Permanent hypoparathyroidism was documented in 4(4%) and 3(1.8%) and transient hypoparathyroidism in 5 (6%) and 4 (2.8%) cases in groups 1 and 2, respectively; p value not significant. Permanent hypoparathyroidism and transient RLN palsy were recorded in 9 (29%) and 8 (25%) patients, respectively in those patients who underwent second thyroid surgery (P < 0.05). Conclusion: Total or near-total thyroidectomy is effective and safe for the surgical treatment of bilateral multinodular goiter to prevent recurrence and to eliminate the need for completion thyroidectomy in case of final diagnosis of incidental thyroid malignancy.

Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands

Robotic assisted transaxillary surgery (RATS) is a minimally invasive approach for the removal of the thyroid and/or parathyroid glands through the axilla. This anatomically directed technique, popularized by Chung, eliminates a visible scar and affords excellent high definition optics of the cervical anatomy. We report an initial series of single access RATS in the U.S. The prospective endocrine surgery database at a tertiary care center was used to capture all patients who underwent RATS between October 2009 and March 2010. All procedures were performed using a single transaxillary incision. Fourteen operations were performed on 13 patients. Indications for RATS were indeterminate thyroid nodules in 11 patients, the need for completion thyroidectomy in 1 patient, and primary hyperparathyroidism in 2 patients. For patients who underwent robotic assisted thyroid lobectomy, the median thyroid nodule size was 2.1 cm (range, 0.8-2.8 cm), and the median body mass index was 25.33 (range, 21.3-34.4). Mean and median total operative times for robotic assisted thyroid lobectomies were 142 minutes and 137 minutes respectively (range, 113-192 minutes). Operative time for the 2 patients who underwent robotic assisted parathyroidectomy was 115 and 102 minutes. Minor complications occurred in 4 patients (28.5%), with no significant perioperative morbidity or mortality. RATS is feasible. We believe that further study of the RATS technique for removing thyroid lobes and parathyroid glands is warranted. This initial series suggests that careful, continued investigation is necessary prior to routine implementation into clinical practice across the U.S.

Five‐year Follow‐up of a Randomized Clinical Trial of Total Thyroidectomy versus Dunhill Operation versus Bilateral Subtotal Thyroidectomy for Multinodular Nontoxic Goiter

The extent of thyroid resection in multinodular nontoxic goiter (MNG) is controversial. The aim of the present study was to evaluate results of various thyroid resection modes, with special emphasis put on the recurrence rate and morbidity rate, in a 5-year follow-up. From 01/2000 through 12/2003, 600 consenting patients with MNG qualified for thyroidectomy at our institution were randomized to three groups equal in size, n = 200 in each. Patients in group A underwent total thyroidectomy (TT); patients in group B underwent Dunhill operation (DO), whereas patients in group C underwent bilateral subtotal thyroidectomy (BST). All patients were subjected to ultrasonographic, cytological, and biochemical follow-up at least for 60 months postoperatively. The primary outcome measure was prevalence of recurrent goiter and need for redo surgery. The secondary outcome measure was the postoperative morbidity rate (hypoparathyroidism and recurrent laryngeal nerve injury). Recurrent goiter was found in 0.52% TT versus 4.71% DO versus 11.58% BST (p = 0.01 for TT versus DO, p = 0.02 for DO versus BST, p < 0.001 for TT versus BST), and completion thyroidectomy was necessary in 0.52% TT versus 1.57% DO versus 3.68% BST (p = 0.03 for TT versus BST). Transient postoperative hypoparathyroidism was present in 10.99% versus 4.23% versus 2.1% (p = 0.007 for TT versus DO, p < 0.001 for TT versus BST), whereas the recurrent laryngeal nerve injury rate was 5.49% and 1.05% TT versus 4.23% and 0.79% DO versus 2.1% and 0.53% BST (transient and permanent, respectively; p = 0.007 for transient events TT versus BST). Total thyroidectomy can be regarded as the procedure of choice for patients with MNG. It is associated with a significantly lower incidence of goiter recurrence and less frequent need for completion thyroidectomy than other more limited thyroid resections. However, TT involves a significantly higher risk of postoperative transient but not permanent hypoparathyroidism and recurrent laryngeal nerve paresis.

Five‐Year Follow‐up of a Randomized Clinical Trial of Unilateral Thyroid Lobectomy with or Without Postoperative Levothyroxine Treatment

The aim of this study was to compare the prevalence of recurrent nodular goiter in the contralateral thyroid lobe among patients after unilateral thyroid lobectomy for unilateral multinodular goiter (MNG) receiving versus not receiving postoperative prophylactic levothyroxine (LT4) treatment. From January 2000 through December 2003, 150 consenting patients underwent a unilateral thyroid lobectomy for unilateral MNG at our institution. They were randomized to two groups with 75 patients in each group. Patients in group A received prophylactic LT4 treatment postoperatively (dose range 75-125 microg/day to maintain thyroid-stimulating hormone values below 1.0 mU/L), whereas patients in group B received no postoperative LT4 treatment. All the patients underwent ultrasonographic, cytologic, and biochemical follow-up for at least 60 months postoperatively. The primary outcome was the prevalence of recurrent goiter in the contralateral thyroid lobe. The secondary outcome was the reoperation rate for recurrent goiter. The outcomes were stratified according to individual iodine metabolism status assessed by urinary iodine excretion. During the 5-year follow-up, among patients receiving vs. not receiving LT4, recurrent goiter within the contralateral thyroid lobe was found in 1.4% vs. 16.7% of patients, respectively (p = 0.001). Moreover, 1.4% vs. 8.3%, respectively, of patients receiving vs. not receiving LT4 required contralateral thyroid lobe surgery (p = 0.05). LT4 decreased the recurrence rate among iodine-deficient patients (3.4% vs. 36%, respectively; p = 0.002) but not among iodine-sufficient patients (0% vs. 6.4%, respectively; p = 0.09). Prophylactic LT4 treatment significantly decreased the recurrence rate of nodular goiter in the contralateral thyroid lobe and the need for completion thyroidectomy, mostly among patients with iodine deficiency.

Micromedullary Thyroid Cancer: How Micro Is Truly Micro?

The aggressive nature of medullary thyroid cancer (MTC) is evidenced by its propensity to present early with lymph node (LN) metastases. The clinical significance of sporadic MTC < or =1 cm (micro-MTC) is not clearly defined. We performed a retrospective review of the clinical, laboratory, and pathologic data for all patients treated or followed at our institution for sporadic micro-MTC from 1987 through 2008. A total of 18 patients met the criteria for inclusion in our study. All tumors were unifocal and C-cell hyperplasia distant from the tumors was uniformly absent. Fourteen (78%) patients underwent total thyroidectomy, and the remaining four (22%) patients with tumors < or =0.5 cm had lobectomy with isthmusectomy alone. Four (22%) patients were found to have LN metastases. However, none of the nine patients with tumors <0.5 cm had clinical evidence of LN metastases. Patients were followed for a median of 3.3 (mean, 4.5) years, and there were no deaths. Postoperative calcitonin levels were available for all patients, of whom 14 had normal levels (range, 0-3.9 pg/ml). The four patients with elevated postoperative calcitonin levels (range, 6.3-644 pg/ml) had tumors ranging from 0.7-0.9 cm in size. Tumors <0.5 cm were associated with a complete absence of clinically detectable nodal disease or elevated postoperative calcitonin levels. The complete absence of multifocal or bilateral disease argues against the need for completion thyroidectomy for sporadic micro-MTC.

The advantage of near-total thyroidectomy to avoid postoperative hypoparathyroidism in benign multinodular goiter

In recent years, total or near-total thyroidectomy has emerged as a surgical option to treat patients with multinodular goiter, especially in endemic iodine-deficient regions. The aim of this study was to compare the complication rates of total and near-total thyroidectomy in multinodular goiter and the incidence of thyroid cancer requiring radioactive iodine ablation and completion thyroidectomy between groups. Patients with euthyroid multinodular goiter without any preoperative suspicion of malignancy, history of familial thyroid cancer, or previous exposure to radiation were randomized (according to a random table) to total thyroidectomy (group 1, n = 104) and near-total thyroidectomy leaving less than 2 g (group 2, n = 112). There were no persistent complications. The incidence of transient hypoparathyroidism in group 1 (26%) was significantly higher than in group 2 (9.8%) (p < 0.001). The rate of asymptomatic hypocalcemia in group 2 (7.4%) was lower than in group 1 (27%) (p < 0.001). The incidence of papillary cancer was 9.6% in group 1 and 12.5% in group 2 (p > 0.05). None of the patients underwent completion thyroidectomy before ablative therapy. Ten patients were found to have the histological criteria for radioactive iodine ablation. Of these 10 patients, four were in group 1 and six were in group 2 (p > 0.05). In conclusion, we recommend near-total thyroidectomy in multinodular goiter instead of total or subtotal thyroidectomy. While near-total thyroidectomy and total thyroidectomy obviate the need for completion thyroidectomy in incidentally found thyroid cancer, and while there is no difference in the rate of recurrent laryngeal nerve palsy between the two methods, near-total thyroidectomy causes a significantly lower rate of hypoparathyroidism compared to total thyroidectomy.