Sheryl T. Y. Htoo, Samuel J. Beaujean, Yousaf Mahmood, F. Alfonso
Ectopic thyroid occurs when the medial descent of the thyroid gland takes place inappropriately. Flurodeoxyglucose (FDG) uptake on the normal thyroid gland is rare. Etiologies for the FDG uptake include infection, inflammation, and malignancy. We report a rare case of ectopic thyroid which was suspected as metastatic lymph node on positron emission tomography-computerized tomography (PET-CT) scan during staging of esophageal adenocarcinoma. A 76-year-old man with no past notable chronic diseases was diagnosed with adenocarcinoma at the gastroesophageal (GE) junction. He was referred to the oncologist, who ordered FDG-PET-CT scan for the staging of cancer. On PET-CT scan, hypermetabolic focus measuring 2.2×2.1 cm with SUVmax 3.4 was present in the left supraclavicular region, which raised concerns for the metastatic disease to the lymph node. Fine-needle aspiration via ultrasound-guided approach was utilized to obtain biopsy, which resulted as benign thyroid tissue. To verify, repeat core biopsy was taken via CT-guided approach, the pathology again confirms benign thyroid tissue. No further intervention was proceeded on the ectopic thyroid. While past studies had shown FDG activity on thyroid lesions, prevalence of malignancy in these thyroid lesions is unclear. There is also no clear correlation between malignancy and SUVmax value. Therefore, we propose further studies are needed to understand the relationship between FDG uptake and thyroid lesions as well as to determine the follow-up algorithm for benign FDG avid lesions.
{"title":"Incidental diagnosis of ectopic thyroid in the work-up of metastatic esophageal cancer: a case report","authors":"Sheryl T. Y. Htoo, Samuel J. Beaujean, Yousaf Mahmood, F. Alfonso","doi":"10.21037/aot-21-24","DOIUrl":"https://doi.org/10.21037/aot-21-24","url":null,"abstract":"Ectopic thyroid occurs when the medial descent of the thyroid gland takes place inappropriately. Flurodeoxyglucose (FDG) uptake on the normal thyroid gland is rare. Etiologies for the FDG uptake include infection, inflammation, and malignancy. We report a rare case of ectopic thyroid which was suspected as metastatic lymph node on positron emission tomography-computerized tomography (PET-CT) scan during staging of esophageal adenocarcinoma. A 76-year-old man with no past notable chronic diseases was diagnosed with adenocarcinoma at the gastroesophageal (GE) junction. He was referred to the oncologist, who ordered FDG-PET-CT scan for the staging of cancer. On PET-CT scan, hypermetabolic focus measuring 2.2×2.1 cm with SUVmax 3.4 was present in the left supraclavicular region, which raised concerns for the metastatic disease to the lymph node. Fine-needle aspiration via ultrasound-guided approach was utilized to obtain biopsy, which resulted as benign thyroid tissue. To verify, repeat core biopsy was taken via CT-guided approach, the pathology again confirms benign thyroid tissue. No further intervention was proceeded on the ectopic thyroid. While past studies had shown FDG activity on thyroid lesions, prevalence of malignancy in these thyroid lesions is unclear. There is also no clear correlation between malignancy and SUVmax value. Therefore, we propose further studies are needed to understand the relationship between FDG uptake and thyroid lesions as well as to determine the follow-up algorithm for benign FDG avid lesions.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41674337","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
other etiologies of hypocalcemia after thyrotoxicosis treatment are rare. We aimed to report the first case of persistent hypocalcemia after thyrotoxicosis factitia treatment. Case Description: A 56-year-old woman presented a thyroid storm at the Emergency Department of a referral hospital in Bangkok, Thailand. Thyrotoxicosis factitia was diagnosed due to a low thyroglobulin (Tg) level together with a history of using levothyroxine as an over-the-counter weight loss pill. Systemic glucocorticoid, together with comprehensive end-organ supportive therapy, was administered to achieve euthyroidism. During admission, the serum calcium level gradually decreased to as low as 6.25 mg/dL, whereas serum intact parathyroid hormone and the alkaline phosphatase (ALP) level considerably increased. Intravenous calcium gluconate, oral calcium carbonate, and vitamin D were administered aggressively to treat severe hypocalcemia. Oral administration of calcium carbonate, ergocalciferol, and alphacalcidol was successfully reduced and discontinued two months after the patient was discharged from the hospital. Conclusions: The abrupt discontinuation of exogenous levothyroxine in the thyrotoxicosis factitia led to an acceleration of the skeletal calcium uptake and resulted in hypocalcemia. Therefore, the close monitoring of the calcium and bone mineral metabolism in patients diagnosed with thyrotoxicosis factitia receiving treatment is recommended.
{"title":"Hungry bone syndrome after thyrotoxicosis factitia complicated with thyroid storm: a case report","authors":"C. Kaewkrasaesin, P. Srichomkwun","doi":"10.21037/aot-21-18","DOIUrl":"https://doi.org/10.21037/aot-21-18","url":null,"abstract":"other etiologies of hypocalcemia after thyrotoxicosis treatment are rare. We aimed to report the first case of persistent hypocalcemia after thyrotoxicosis factitia treatment. Case Description: A 56-year-old woman presented a thyroid storm at the Emergency Department of a referral hospital in Bangkok, Thailand. Thyrotoxicosis factitia was diagnosed due to a low thyroglobulin (Tg) level together with a history of using levothyroxine as an over-the-counter weight loss pill. Systemic glucocorticoid, together with comprehensive end-organ supportive therapy, was administered to achieve euthyroidism. During admission, the serum calcium level gradually decreased to as low as 6.25 mg/dL, whereas serum intact parathyroid hormone and the alkaline phosphatase (ALP) level considerably increased. Intravenous calcium gluconate, oral calcium carbonate, and vitamin D were administered aggressively to treat severe hypocalcemia. Oral administration of calcium carbonate, ergocalciferol, and alphacalcidol was successfully reduced and discontinued two months after the patient was discharged from the hospital. Conclusions: The abrupt discontinuation of exogenous levothyroxine in the thyrotoxicosis factitia led to an acceleration of the skeletal calcium uptake and resulted in hypocalcemia. Therefore, the close monitoring of the calcium and bone mineral metabolism in patients diagnosed with thyrotoxicosis factitia receiving treatment is recommended.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44249546","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Beyond hypocalcemia: the impact of permanent post-operative hypoparathyroidism on patient quality of life—a narrative review","authors":"Vaninder K. Dhillon, K. F. Moseley","doi":"10.21037/aot-22-10","DOIUrl":"https://doi.org/10.21037/aot-22-10","url":null,"abstract":"","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48429360","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Thyroid cancer survivorship: the patient experience","authors":"Marika D. Russell, Amanda Silver Karcioglu","doi":"10.21037/aot-22-14","DOIUrl":"https://doi.org/10.21037/aot-22-14","url":null,"abstract":"","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47726491","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Telemedicine as a new platform of care: assessing quality of care for the endocrine surgical patient—a narrative review","authors":"Jerica L Podrat, F. Zheng","doi":"10.21037/aot-22-7","DOIUrl":"https://doi.org/10.21037/aot-22-7","url":null,"abstract":"","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44544640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Radiofrequency ablation of thyroid nodules: a narrative review and perspective on the patient experience and quality of life","authors":"Julia E. Noel, Zoe H Fullerton","doi":"10.21037/aot-22-12","DOIUrl":"https://doi.org/10.21037/aot-22-12","url":null,"abstract":"","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41816001","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background and Objective: By age 50, the majority of Americans will have one or more thyroid nodules incidentally discovered. Thyroid nodules may be biopsied via fine-needle-aspiration (FNA), and nearly 100,000 nodules are graded cytologically indeterminate every year in the US, yielding a diagnostic dilemma. Molecular testing has emerged as a modality to aid in risk stratifying these indeterminate thyroid nodules to avoid unnecessary diagnostic surgery. To date, few studies have investigated quality of life (QOL) associated with molecular testing for indeterminate thyroid nodules. Our aim in this review is to discuss the findings, implications, and limitations of these studies. Methods: A literature review was performed using PubMed to search all original articles published in the English language over the last 30 years that assessed QOL in patients undergoing molecular testing for indeterminate thyroid nodules. Key Content and Findings: The two most relevant studies assessed QOL in patients with indeterminate cytology who underwent molecular testing followed by observation or surgery, both at an initial timepoint and then longitudinally. Patients with benign cytology and a benign molecular test result experienced similar QOL. Patients with malignant cytology had increased impairment of daily life but otherwise no other differences in QOL, compared to those with a suspicious molecular test. A suspicious molecular test was associated with worse initial QOL compared to a benign molecular test. Patients who underwent surgery for suspicious molecular test reported improved QOL after surgery compared to before. The small subset of patients opting for active surveillance after receiving a suspicious molecular test reported similar QOL as those with a benign molecular test. Conclusions: While there was some loss to follow up, these studies may provide reassurance that patients view a benign molecular test similarly to benign cytology. A suspicious molecular result may initially be associated with worse QOL compared to a benign molecular result, but QOL differences seem to disappear at early follow up, likely reflecting the large proportion of patients with suspicious molecular testing who undergo surgery and subsequently report improvement in nearly all QOL domains compared to their baseline.
{"title":"A narrative review of molecular testing for indeterminate thyroid nodules: living with the results","authors":"V. Sant, M. Livhits","doi":"10.21037/aot-22-13","DOIUrl":"https://doi.org/10.21037/aot-22-13","url":null,"abstract":"Background and Objective: By age 50, the majority of Americans will have one or more thyroid nodules incidentally discovered. Thyroid nodules may be biopsied via fine-needle-aspiration (FNA), and nearly 100,000 nodules are graded cytologically indeterminate every year in the US, yielding a diagnostic dilemma. Molecular testing has emerged as a modality to aid in risk stratifying these indeterminate thyroid nodules to avoid unnecessary diagnostic surgery. To date, few studies have investigated quality of life (QOL) associated with molecular testing for indeterminate thyroid nodules. Our aim in this review is to discuss the findings, implications, and limitations of these studies. Methods: A literature review was performed using PubMed to search all original articles published in the English language over the last 30 years that assessed QOL in patients undergoing molecular testing for indeterminate thyroid nodules. Key Content and Findings: The two most relevant studies assessed QOL in patients with indeterminate cytology who underwent molecular testing followed by observation or surgery, both at an initial timepoint and then longitudinally. Patients with benign cytology and a benign molecular test result experienced similar QOL. Patients with malignant cytology had increased impairment of daily life but otherwise no other differences in QOL, compared to those with a suspicious molecular test. A suspicious molecular test was associated with worse initial QOL compared to a benign molecular test. Patients who underwent surgery for suspicious molecular test reported improved QOL after surgery compared to before. The small subset of patients opting for active surveillance after receiving a suspicious molecular test reported similar QOL as those with a benign molecular test. Conclusions: While there was some loss to follow up, these studies may provide reassurance that patients view a benign molecular test similarly to benign cytology. A suspicious molecular result may initially be associated with worse QOL compared to a benign molecular result, but QOL differences seem to disappear at early follow up, likely reflecting the large proportion of patients with suspicious molecular testing who undergo surgery and subsequently report improvement in nearly all QOL domains compared to their baseline.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48482143","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Surgeon-performed ultrasound (US) is increasingly embraced by surgeons worldwide as an integral part of patient assessment. Its usage within Australian and New Zealand Endocrine Surgeons (ANZES) is not well documented. This study aims to evaluate current usage patterns and to determine suitable future training models. Methods: An online survey was sent to members of ANZES between August and September 2021, with emphasis on practice demographics, access and usage of US, US training and accreditation. Results: Of 125 surveys sent, 52 were returned (42%). Most respondents were metropolitan based (90%), worked in both public and private sectors (81%) and practiced both breast and endocrine surgery, with some general surgery (38%). A preponderance of surgeons had access to US equipment (73%) and 42% believed US is essential for best practice in endocrine surgery. Thirty-seven percent of surgeons performed more than 20 US per month, and 40% of respondents perform US guided fine needle aspiration biopsy (FNAB). Ultrasounds were also used in theatre as an adjunct for parathyroid (73%), thyroid (38%) and cervical lymph node surgery (44%). Most surgeons underwent formal training post Fellowship (81%) and 38% have Australasian Society for Ultrasound in Medicine Certificate in Clinician Performed Ultrasound (ASUM CCPU) accreditation. Surgeons strongly favoured post fellowship US training for future endocrine surgical trainees (88%). Conclusions: The survey demonstrates that surgeon-performed US is significantly embraced by endocrine surgeons, with 80% of respondents overall and 92.9% of those with access to US, indicating that surgeon-performed US is essential or at least very important for best practice. US is used frequently in the office and theatre settings. There is an important need for the development and formalization of endocrine US training courses from the SET/Registrar level through to the post-Fellowship environment.
{"title":"Evaluation of surgeon-performed ultrasound usage amongst Australian and New Zealand Endocrine Surgeons","authors":"Jessica Wong, J. A. Miller, Ian Bennett","doi":"10.21037/aot-22-8","DOIUrl":"https://doi.org/10.21037/aot-22-8","url":null,"abstract":"Background: Surgeon-performed ultrasound (US) is increasingly embraced by surgeons worldwide as an integral part of patient assessment. Its usage within Australian and New Zealand Endocrine Surgeons (ANZES) is not well documented. This study aims to evaluate current usage patterns and to determine suitable future training models. Methods: An online survey was sent to members of ANZES between August and September 2021, with emphasis on practice demographics, access and usage of US, US training and accreditation. Results: Of 125 surveys sent, 52 were returned (42%). Most respondents were metropolitan based (90%), worked in both public and private sectors (81%) and practiced both breast and endocrine surgery, with some general surgery (38%). A preponderance of surgeons had access to US equipment (73%) and 42% believed US is essential for best practice in endocrine surgery. Thirty-seven percent of surgeons performed more than 20 US per month, and 40% of respondents perform US guided fine needle aspiration biopsy (FNAB). Ultrasounds were also used in theatre as an adjunct for parathyroid (73%), thyroid (38%) and cervical lymph node surgery (44%). Most surgeons underwent formal training post Fellowship (81%) and 38% have Australasian Society for Ultrasound in Medicine Certificate in Clinician Performed Ultrasound (ASUM CCPU) accreditation. Surgeons strongly favoured post fellowship US training for future endocrine surgical trainees (88%). Conclusions: The survey demonstrates that surgeon-performed US is significantly embraced by endocrine surgeons, with 80% of respondents overall and 92.9% of those with access to US, indicating that surgeon-performed US is essential or at least very important for best practice. US is used frequently in the office and theatre settings. There is an important need for the development and formalization of endocrine US training courses from the SET/Registrar level through to the post-Fellowship environment.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42231126","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. L. M. D. Nova, Álvaro Valdés de Anca, Emma Torres Mínguez, E. Martín-Pérez
Objective: To discuss the cervical recurrence risk factors of medullary thyroid carcinoma (MTC) and the indications, recommended surgical strategy and outcomes of cervical reintervention. Background: Unlike differentiated thyroid carcinoma, MTC is not sensitive to radioactive iodine, thus making surgery the cornerstone of the treatment of these patients. Initial surgery consists of total thyroidectomy with bilateral central compartment (level VI) lymph node dissection, being lateral lymphadenectomy indicated whenever macroscopic cervical lymph node metastases are present. However, up to 50% of patients with presumed curative surgery have persistent elevated serum calcitonin levels, in most of the cases due to inadvertent residual malignant tissue or metastases, and 10–25% develop cervical recurrence. Nodal disease is the main form of structural recurrence, with a median time until diagnosis of 4 years since initial surgery. Both serum calcitonin levels and the evidence of macroscopic recurrence/persistence should be used to guide the indication for reoperation. If biochemical cure has not been achieved and there is no evidence of structural disease, a watch-and-wait approach might be adopted. However, surgery is indicated in the presence of structural recurrence or after a sub-optimal initial procedure. Metastatic workup is necessary before reoperation as the extent of the disease will guide the surgical strategy. This metastatic workup consists mainly in imaging techniques [computed tomography (CT)-scan, magnetic resonance imaging (MRI), bone scintigraphy and neck-ultrasound (US)], nuclear medicine techniques [positron emission tomography (PET)/CT] or invasive procedures such as diagnostic laparoscopy. Neck reintervention is associated with a higher risk of complications than during primary surgery, mainly recurrent laryngeal nerve injury, permanent hypoparathyroidism, and thoracic duct leak, and therefore reintervention should be carefully planned and performed by experienced endocrine surgeons. Reintervention can be planned either with a curative intent or as a palliative procedure. If planned with a curative intent, a compartment-oriented lymph-node dissection is the recommended surgical strategy, and the goal should be achieving biochemical cure. Methods: Narrative review of articles published between 1990 and 2021. An additional review of the articles referenced in the bibliography of the included articles was performed. The search was conducted in PubMed and Web of Science. Conclusions: Reintervention, even if associated with a higher morbidity, does not imply a worse overall prognosis if biochemical cure is achieved. On the contrary, it can be planned as a palliative procedure aimed at minimizing complications derived from compromise of vital cervical structures such as airway, esophagus, or major vessels.
目的:探讨甲状腺髓样癌(MTC)宫颈复发的危险因素及宫颈再干预的适应证、推荐手术策略和疗效。背景:与分化型甲状腺癌不同，MTC对放射性碘不敏感，因此手术是治疗这些患者的基石。最初的手术包括全甲状腺切除术和双侧中央室(VI层)淋巴结清扫，当肉眼可见颈部淋巴结转移时，需要行侧淋巴结清扫。然而，高达50%的接受手术治疗的患者血清降钙素水平持续升高，在大多数情况下是由于无意中残留的恶性组织或转移，10-25%的患者发生宫颈复发。淋巴结疾病是结构性复发的主要形式，从初次手术到诊断的中位时间为4年。血清降钙素水平和宏观复发/持续的证据应作为指导再手术指征的依据。如果生化治疗尚未实现，也没有证据表明存在结构性疾病，则可能采用观察和等待的方法。然而，手术是指在存在结构性复发或在次优初始手术后。再手术前必须进行转移性检查，因为疾病的程度将指导手术策略。这种转移性检查主要包括成像技术[计算机断层扫描(CT)-扫描，磁共振成像(MRI)，骨显像和颈部超声(US)]，核医学技术[正电子发射断层扫描(PET)/CT]或侵入性手术，如诊断腹腔镜检查。颈部再干预与初次手术相比，并发症的风险更高，主要是喉返神经损伤、永久性甲状旁腺功能低下和胸导管泄漏，因此，再干预应由经验丰富的内分泌外科医生精心计划和实施。再干预既可以以治疗为目的，也可以作为姑息治疗。如果计划治疗的目的，室导向淋巴结清扫是推荐的手术策略，目标应该是实现生化治愈。方法:对1990年至2021年间发表的文章进行叙述性回顾。对纳入文章的参考书目中引用的文章进行了额外的审查。搜索是在PubMed和Web of Science上进行的。结论:再干预，即使与更高的发病率相关，但如果实现生化治愈，并不意味着总体预后更差。相反，它可以作为一种姑息性手术来规划，目的是尽量减少因颈椎重要结构(如气道、食道或主要血管)受损而引起的并发症。
{"title":"Narrative review of neck reinterventions for medullary thyroid carcinoma: indications and outcomes","authors":"J. L. M. D. Nova, Álvaro Valdés de Anca, Emma Torres Mínguez, E. Martín-Pérez","doi":"10.21037/aot-21-12","DOIUrl":"https://doi.org/10.21037/aot-21-12","url":null,"abstract":"Objective: To discuss the cervical recurrence risk factors of medullary thyroid carcinoma (MTC) and the indications, recommended surgical strategy and outcomes of cervical reintervention. Background: Unlike differentiated thyroid carcinoma, MTC is not sensitive to radioactive iodine, thus making surgery the cornerstone of the treatment of these patients. Initial surgery consists of total thyroidectomy with bilateral central compartment (level VI) lymph node dissection, being lateral lymphadenectomy indicated whenever macroscopic cervical lymph node metastases are present. However, up to 50% of patients with presumed curative surgery have persistent elevated serum calcitonin levels, in most of the cases due to inadvertent residual malignant tissue or metastases, and 10–25% develop cervical recurrence. Nodal disease is the main form of structural recurrence, with a median time until diagnosis of 4 years since initial surgery. Both serum calcitonin levels and the evidence of macroscopic recurrence/persistence should be used to guide the indication for reoperation. If biochemical cure has not been achieved and there is no evidence of structural disease, a watch-and-wait approach might be adopted. However, surgery is indicated in the presence of structural recurrence or after a sub-optimal initial procedure. Metastatic workup is necessary before reoperation as the extent of the disease will guide the surgical strategy. This metastatic workup consists mainly in imaging techniques [computed tomography (CT)-scan, magnetic resonance imaging (MRI), bone scintigraphy and neck-ultrasound (US)], nuclear medicine techniques [positron emission tomography (PET)/CT] or invasive procedures such as diagnostic laparoscopy. Neck reintervention is associated with a higher risk of complications than during primary surgery, mainly recurrent laryngeal nerve injury, permanent hypoparathyroidism, and thoracic duct leak, and therefore reintervention should be carefully planned and performed by experienced endocrine surgeons. Reintervention can be planned either with a curative intent or as a palliative procedure. If planned with a curative intent, a compartment-oriented lymph-node dissection is the recommended surgical strategy, and the goal should be achieving biochemical cure. Methods: Narrative review of articles published between 1990 and 2021. An additional review of the articles referenced in the bibliography of the included articles was performed. The search was conducted in PubMed and Web of Science. Conclusions: Reintervention, even if associated with a higher morbidity, does not imply a worse overall prognosis if biochemical cure is achieved. On the contrary, it can be planned as a palliative procedure aimed at minimizing complications derived from compromise of vital cervical structures such as airway, esophagus, or major vessels.","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41640598","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Marissa Mencio, G. Fernández-Ranvier, W. Inabnet, H. Suh
Thyroidectomy is the most common procedure performed in endocrine surgery. The standard surgical approach is via the anterior neck using a Kocher incision. Over the past two decades, minimally invasive and remote endoscopic approaches to thyroid surgery have emerged as surgeons attempt to improve the cosmesis of the surgery and move towards “scarless” approaches. Remote access techniques utilize strategically hidden incisions removed from the highly visible anterior neck. Rapidly emerging data shows these have comparable outcomes to the conventional open approach and result in high patient satisfaction and improved quality of life in thyroidectomy patients. The transoral endoscopic vestibular approach (TOETVA) and the robotic bilateral axillo-breast approach (BABA) are the two most common remote access approaches to date. In TOETVA, three incisions within the vestibular mucosa are used to access the thyroid. The use of standard laparoscopic instruments and a slightly less steep learning curve compared to other techniques have led to a successful adoption in North America. The robotic BABA technique uses 4 small, widely spaced incisions to provide ideal triangulation of instruments with a familiar midline view of the thyroid. Due to the robotic platform, it has a steeper learning curve but has seen great success in Asia. This article will review these two techniques, offering a comparison and highlighting the clinical trend and future
{"title":"All roads lead to the thyroid gland: review of two popular “scarless” thyroidectomy approaches","authors":"Marissa Mencio, G. Fernández-Ranvier, W. Inabnet, H. Suh","doi":"10.21037/AOT-20-47","DOIUrl":"https://doi.org/10.21037/AOT-20-47","url":null,"abstract":"Thyroidectomy is the most common procedure performed in endocrine surgery. The standard surgical approach is via the anterior neck using a Kocher incision. Over the past two decades, minimally invasive and remote endoscopic approaches to thyroid surgery have emerged as surgeons attempt to improve the cosmesis of the surgery and move towards “scarless” approaches. Remote access techniques utilize strategically hidden incisions removed from the highly visible anterior neck. Rapidly emerging data shows these have comparable outcomes to the conventional open approach and result in high patient satisfaction and improved quality of life in thyroidectomy patients. The transoral endoscopic vestibular approach (TOETVA) and the robotic bilateral axillo-breast approach (BABA) are the two most common remote access approaches to date. In TOETVA, three incisions within the vestibular mucosa are used to access the thyroid. The use of standard laparoscopic instruments and a slightly less steep learning curve compared to other techniques have led to a successful adoption in North America. The robotic BABA technique uses 4 small, widely spaced incisions to provide ideal triangulation of instruments with a familiar midline view of the thyroid. Due to the robotic platform, it has a steeper learning curve but has seen great success in Asia. This article will review these two techniques, offering a comparison and highlighting the clinical trend and future","PeriodicalId":92168,"journal":{"name":"Annals of thyroid","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2021-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44371283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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