Objective
To investigate intraoperative nerve monitoring (IONM) use among thyroid surgeons.
Methods
A 25‐question survey was used to assess attitudes regarding IONM use. Surveys were sent to surgeons ...registered to the American Academy of Otolaryngology–Head and Neck Surgery, International Association of Endocrine Surgeons, and American Head and Neck Society.
Results
Among 1,015 respondents, 83% reported using IONM (65.1% always using IONM and 18.1% reporting selective use). For selective users, a majority reported using IONM for reoperative cases (95.1%) and in cases with preoperative vocal cord paralysis (59.8%). When comparing location, there was a significant difference in IONM implementation (P < 0.001), with 70.4% of North American responders using it ubiquitously compared to 27.4% of non‐North American responders. Preoperative laryngeal exam was performed more universally by North American surgeons and more selectively by non‐North American surgeons (P < 0.001). Other attitudes toward their implementation and the postoperative laryngeal exam were similar. Surgeons ≤45 years of age and those with ≤15 years of practice used IONM more than their peers (P < 0.001). Thyroid surgery volume, fellowship training, and type of practice had no bearing on IONM use.
Conclusion
The prevalence of IONM in thyroid and parathyroid surgeries has increased significantly over the past decade, with 83% of surgeons using IONM in some or all cases. Although IONM use may be more ubiquitous in North America, attitudes toward its implementation and pre‐ and postoperative laryngeal exams are fairly uniform. IONM use is more prevalent among younger surgeons, whereas its use has no correlation with thyroid surgery volume or type of practice.
Level of Evidence
4 Laryngoscope, 130:1097–1104, 2020
Surgical management of thyroid cancer requires careful consideration of the recurrent laryngeal nerve and its impact on glottic function. Management of the compromised recurrent laryngeal nerve is a ...complex task, requiring synthesis of multiple elements. The surgeon must have an appreciation for preoperative recurrent laryngeal nerve function, intraoperative anatomic and electromyographic information, disease characteristics, and relevant patient factors. Preoperative clinical evaluation including preoperative laryngoscopy and assessment of recurrent laryngeal nerve risk is essential to formulating a surgical plan and providing appropriate patient counseling. Intraoperative neuromonitoring information has significant implications for surgical management of the injured or invaded recurrent laryngeal nerve and informs strategy with respect to staging of bilateral surgery. Disease characteristics and patient-related factors, including patient preference, must be considered with intraoperative decision-making. Multidisciplinary discussion and patient communication are essential for effective management and successful surgical outcome.
To assess relative clinical and economic performance of the revised American Thyroid Association (ATA) thyroid cancer guidelines compared to current standard of care.
Diagnosis of thyroid cancer in ...the United States has tripled whereas mortality has only marginally increased. Most patients present with small papillary carcinomas and have historically received at least a total thyroidectomy as a treatment. In 2015, the ATA released the revised guidelines recommending an option for active surveillance (AS) of small papillary thyroid carcinoma and thyroid lobectomy for larger unifocal tumors.
We created a Markov microsimulation model to evaluate the performance of the ATA's 2015 guidelines compared to the ATA's 2009 guidelines. We modeled a cohort of simulated patients with demographic and thyroid nodule characteristics representative of those presenting clinically in the United States. Outcome measures include life expectancy, quality-adjusted life years, costs, and frequency of surgical adverse events.
In our base case analysis, the ATA 2015 strategy dominates the ATA 2009 strategy. The ATA 2015 strategy delivers greater discounted average quality-adjusted life years (13.09 vs 12.43) at a lower discounted average cost ($14,752 vs $20,126). Deaths due to thyroid cancer under the 2015 strategy are higher than the 2009 strategy but this is offset by a reduction in surgical deaths, leading to greater average life expectancy under the ATA 2015 strategy. The optimal strategy is sensitive to patients who experience a greater decrement in quality of life while undergoing AS.
The ATA 2015 Guidelines represent a cost-effective strategy regarding AS and extent of surgery.
Introduction
Aggressive variants of papillary thyroid cancer (PTC) have been described with increasing frequency. These variants include diffuse sclerosing variant, tall cell variant, columnar cell ...variant, solid variant, and hobnail variant.
Methods
We have performed a review of the more aggressive variants of PTC with respect to main characteristics, histological and molecular features, and the consequences that the knowledge of these variants should have in the treatment of the patients.
Results
At the present time, we do not know the prognostic value of these aggressive PTC variants. The extent of the surgical treatment and adjuvant therapy necessary should be decided on the basis of the extent of the tumor at presentation and the opinion of experienced clinicians.
Conclusion
These aggressive variants should be known by clinicians, to avoid underdiagnosis, and treated according to the latest recommendations in the literature.
Parathyroid cancer: An update Rodrigo, Juan P.; Hernandez-Prera, Juan C.; Randolph, Gregory W. ...
Cancer treatment reviews,
06/2020, Letnik:
86
Journal Article
Recenzirano
Odprti dostop
•Parathyroid cancer comprises 0.5–5% of patients with primary hyperparathyroidism.•15–70% of sporadic parathyroid carcinomas carry a somatic mutation of the CDC73 gene.•Complete surgical resection is ...the only known curative treatment.•Recurrence is frequent (20–50%) but long-term survival is favorable due to its slow-growing nature.
Parathyroid cancer (PC) is a rare malignant tumor which comprises 0.5–5% of patients with primary hyperparathyroidism (PHPT). Most of these cancers are sporadic, although it may also occur as a feature of various genetic syndromes including hyperparathyroidism-jaw tumor syndrome (HPT-JT) and multiple endocrine neoplasia (MEN) types 1 and 2A. Although PC is characterized by high levels of serum ionized calcium (Ca) and parathyroid hormone (PTH), the challenge to the clinician is to distinguish PC from the far more common entities of parathyroid adenoma (PA) or hyperplasia, as there are no specific clinical, biochemical, or radiological characteristic of PC. Complete surgical resection is the only known curative treatment for PC with the surgical approach during initial surgery strongly influencing the outcome. In order to avoid local recurrence, the lesion must be removed en-bloc with clear margins. PC has high recurrence rates of up to 50% but with favorable long-term survival rates (10-year overall survival of 60–70%) due to its slow-growing nature. Most patients die not from tumor burden directly but from uncontrolled severe hypercalcemia. In this article we have updated the information on PC by reviewing the literature over the past 10 years and summarizing the findings of the largest series published in this period.
Background
Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present.
Methods
A multidisciplinary panel of distinguished experts ...from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946‐2017), Cochrane SR (2005‐2017), CT databases (1997‐2017), and Web of Science (1945‐2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness.
Results
Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed.
Conclusion
Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.
Background
The data on the advantages of intraoperative nerve monitoring (IONM) during thyroid surgeries is inconsistent. Our objective was to study the patterns of use of IONM in thyroid surgery ...among American Head and Neck Society (AHNS) members.
Method
A web‐based survey was e‐mailed to all members of the AHNS.
Results
A total of 275 surgeons completed the survey. Seventy‐two percent reported using IONM routinely. Routine use of IONM was associated with longer period in practice. Twenty‐one percent only used IONM selectively in high‐risk cases. Most surgeons would consider aborting the procedure in cases of loss of signal without continuing to the contralateral side. Finally, only 19% of surgeons attempt to identify the external branch of the superior laryngeal nerve (EBSLN).
Conclusions
The majority of AHNS surgeons routinely use IONM during thyroid surgery as a real‐time decision‐making tool. However, IONM for preservation of the EBSLN is underutilized.
Objective
The Checkpoint nerve stimulator (Checkpoint Surgical, Cleveland, OH) is a U.S. Food and Drug Administration‐approved device for neural localization and monitoring during surgery. Its ...safety, efficacy, and reliability for neural monitoring during thyroid and parathyroid surgery have not been compared to more standard formats of neural monitoring.
Study Design
Retrospective review.
Methods
Vagal, recurrent, and superior laryngeal nerve monitoring were performed using both the Checkpoint stimulator and Medtronic NIM 3.0 laryngeal electromyography endotracheal tube (Medtronic, Jacksonville, FL) during thyroid and parathyroid surgery. A total of 21 operated sides in 15 patients were included for analysis. Latency and amplitude data for the Checkpoint stimulator were recorded using the NIM monitor and compared to normative endotracheal tube surface electrode data.
Results
Mean amplitude using the Checkpoint stimulator was 574.6 microvolts (μV), 1060.6 μV, and 182.8 μV for the vagus, recurrent laryngeal, and superior laryngeal nerves, respectively. Mean amplitude using standard laryngeal electromyography was 709 μV, 1077.0 μV, and 183.7 μV for the same nerves. Mean latency was significantly shorter with stimulation of the recurrent laryngeal nerve compared to the vagus nerve with both stimulators (P < 0.001). No neural injuries occurred during the study.
Conclusion
The Checkpoint stimulator is a safe and reliable alternative to traditional laryngeal electromyography providing equivalent induced electromyography of the vocalis for neural monitoring during thyroid and parathyroid surgery.
Level of Evidence
4 Laryngoscope, 130:561–565, 2020
Objectives/Hypothesis
Recent American Thyroid Association Guidelines recommend either near‐total/total thyroidectomy or lobectomy for patients with a thyroid nodule suspicious for papillary thyroid ...cancer (PTC) on fine‐needle aspiration (FNA) biopsy (Bethesda V). In this analysis, we aim to assess the cost‐effectiveness of lobectomy in comparison to total thyroidectomy.
Study Design
Cost‐effectiveness analysis.
Methods
A Markov model cost‐effectiveness analysis was performed for a base case followed for 20 years postoperatively. Cost and probabilities data were retrieved from the current literature. Effectiveness was represented by quality‐adjusted life year (QALY).
Results
Total thyroidectomy protocol produced an incremental cost of $2,681.36 and incremental effectiveness of −0.24 QALY as compared to lobectomy protocol (incremental cost‐effectiveness ratio ICER = −$11,188.85/QALY). Sensitivity analysis demonstrated that total thyroidectomy becomes a cost‐effective strategy only if the risk of stages III and IV PTC is 82.4% among patients with suspicious PTC on preoperative FNA. Lobectomy is cost effective and preferred over total thyroidectomy as long as lobectomy complications are less than 50%.
Conclusions
Total thyroidectomy is not just cost prohibitive but also associated with a lower effectiveness compared to lobectomy.
Level of Evidence
2c Laryngoscope, 2020
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