Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• The American Thyroid Association (ATA) guidelines recommend that:
  • Thyroid lobectomy is sufficient:
    • In low-risk patients with differentiated thyroid cancer (DTC):
      • However, the corresponding optimal serum TSH level, and thus whether replacement therapy with levothyroxine (LT4) might be advised, in low-risk patients after lobectomy is still a controversial issue
• In this study Clin Thyroidol 2022;34:67–70, Xu and coworkers:
  • Examined the association between post-surgical TSH levels in patients with papillary thyroid carcinoma (PTC):
    • Who were given LT4 therapy after lobectomy and their risk of structural recurrence
• Methods:
  • This study included adult patients (ages 18 to 75) who underwent thyroid lobectomy for PTC:
    • At the National Cancer Institute and Hospital at the Chinese Academy of Medical Sciences from January 2000 to December 2014
  • Patients without advanced tumors or preoperative evidence of distant metastasis, high-risk aggressive variants, and positive surgical margins were included
  • Staging was assigned according to the American Joint Committee on Cancer staging system (8th edition)
  • The post-surgical risk stratification was assessed according to the 2015 ATA differentiated thyroid cancer guidelines
  • All included patients received thyroid hormone replacement therapy as LT4:
    • Targeting an optimal serum TSH range of 0.5 to 1 mU/L
  • Serum TSH concentrations were determined by electrochemiluminescence immunoassay with a functional sensitivity of at least 0.01 mU/L and a reference range of 0.5 to 4.0 mU/L
  • Physical examination, neck ultrasonography, computed tomography or chest radiography, and serum thyroid tests (TSH, thyroglobulin, and antithyroglobulin antibodies) were assessed every 6 months during the first 5 years and every 12 months thereafter
  • Recurrence-free survival was estimated from the time of surgery for PTC until there was evidence of a structural recurrence
  • The association of mean TSH and structural recurrence was assessed using univar-iate and multivariate Cox regression models with restricted cubic spline
• Results:
  • The study sample included 2297 patients (median age, 42 years; 76.2% women)
  • The mean (±SD) tumor size was 1.23 ±0.98 cm, with 59.2% of patients having a tumor < 1 cm
  • Central neck dissection was performed in 70.9% and lateral neck dissection in 22.6%, respectively
  • At the initial evaluation, 41.2% patients had low-risk of recurrence, 42.4% had intermediate-risk, and 16.4% high-risk of recurrence, according to the 2015 ATA risk stratification guidelines
  • The mean post-surgical TSH level in the cohort was 1.456 ± 2.224 mIU/L
  • Serum TSH values were 0.5 mU/L in 29.1%, in the lower half of the reference range (0.5 to < 2) in 50.6%, in the upper half of the reference range (2.1 to ≤4) in 15%, and above the reference range (>4) in 5.3%
  • During a median follow-up period of 70 months:
    • 167 (7.3%) patients had structural recurrences and 26 died (11 from PTC)
  • Local or regional recurrences developed in 84.4% of patients (37 local, 66 regional, and 38 both), whereas distant metastases developed in 26 (isolated in 12 cases and combined with local or regional recurrences in 14)
  • Recurrences were detected in the:
    • Residual lobe (n = 71)
    • Thyroid bed (n = 6)
    • Central neck (n = 60)
    • Lateral neck (n = 90)
  • Recurrence-free survival rates at 5 and 10 years were 94.7% and 84.7%, respectively
  • 81.4% of the recurrences occurred in patients in the intermediate-to-high-risk group
  • No associations were observed between mean TSH levels and recurrence-free survival in the combined cohort of low-risk and intermediate-to-high-risk groups
  • The only recurrence-free survival difference observed in the stratified univariate analysis was between patients with mean TSH levels in the lower half of the reference range (0.6–2 mU/L, n = 659) versus those above the reference range (>4 mU/L, n = 68) in the intermediate-to-high-risk group (10-year recurrence-free survival by Kaplan–Meier analysis, 84.4% vs. 69.4%, log-rank P = 0.011)
• Conclusions:
  • In this retrospective cohort study, no associations were observed between the mean postoperative serum TSH levels and tumor recurrence among PTC patients who underwent thyroid lobectomy
  • The recurrence-free survival rates were similar between patients whose TSH levels were within the reference range and those with suppressed TSH levels
• Optimal management of DTC includes:
  • The avoidance of overdiagnosis and overtreatment in patients with a low risk of disease recurrence
• Papillary micro-carcinoma represents a very-low-risk tumor and one for which the ATA supports the possibility of active surveillance as a management option
• Furthermore, the ATA recommends thyroid lobectomy for differentiated thyroid cancer:
  • Greater than 1 cm and less than 4 cm with unifocal and intrathyroidal carcinoma without extra-thyroidal extension and clinical evidence of any lymph-node metastases (cN0), in the absence of prior head and neck radiation, familial thyroid carcinoma or clinically detectable cervical node metastases
• This approach has been associated with a favorable outcome and had no negative impact on overall survival according to a systematic literature review
• The advantages of lobectomy include:
  • Fewer surgical complications (less risk of hypocalcemia and recurrent laryngeal-nerve injury) and a lower risk of postoperative hypothyroidism:
    • A large meta-analasis of 32 studies reported an estimated risk of 12% for subclinical hypothyroidism and 4% for clinical hypothyroidism in patients who undergo lobectomy
• For patients with DTC, the ATA guidelines recommend a postoperative TSH level in the mid to lower reference range (0.5–2 mU/L):
  • Therefore, treatment with LT4 in this group is not necessary when the postoperative serum TSH remains below 2 mIU/L
• It should be noted that patients with high pre-operative TSH levels and positive for antithyroid peroxidase antibodies:
  • Might have an increased risk of developing hypothyroidism after lobectomy
• In addition, high postoperative TSH levels (after 1 year):
  • May identify patients with persistent postoperative hypothyroidism after lobectomy
• The disadvantage of lobectomy is:
  • The need for completion thyroidectomy in patients with:
    • A high risk for recurrence, worrisome histologic features, malignant new nodules in the contralateral lobe, or evidence of structural disease on imaging during follow-up
• In this large retrospective study by Xu et al. that included 2297 patients who underwent lobectomy for thyroid cancer, the surgical pathology revealed that 42.4% of patients had an intermediate risk and 16.4% a high risk for recurrence (defined by the 2015 ATA DTC guidelines), despite the preoperative exclusion of high-risk variants, distant metastases, and positive surgical margins
• The fact that a relatively large proportion of patients were at intermediate or high risk and yet did not undergo completion thyroidectomy could explain why structural recurrence developed in 7.3% and thyroid cancer–specific mortality was observed in 11 patients over a follow-up of 70 months
• However, despite the inclusion of these patients, serum TSH levels were not associated with recurrence risks, even in the adjusted model restricted to patients with intermediate or high risk for recurrent disease
• The risk of thyroid malignancy increases with serum TSH, and higher TSH values (even within the normal range), have been associated with a higher frequency of thyroid cancer in patients with nodular thyroid disease
• However, there are conflicting data in the literature concerning the potential role of postsurgical TSH levels regarding the prognosis of low-risk DTC patients
• In a retrospective, propensity score–matched cohort study by Park et al:
  • TSH suppression did not improve clinical outcomes, and serum TSH levels were not associated with recurrence in patients with low-risk DTC who underwent lobectomy
• In addition, no difference in the rate of recurrences was reported among patients with TSH values ranging from less than 0.5 to 4.5 mIU/L in a study by Lee et al:
  • Their analysis showed that there were no differences in recurrence when comparing those with and those without thyroid hormone replacement therapy
• These results suggest the necessity of large prospective studies with rigorous criteria to determine the optimal range of serum TSH levels in low-risk DTC patients, including those who undergo lobectomy:
  • These future studies should consider the risks and benefits of LT4 therapy with regard to thyroid cancer recurrence risks, survival and quality of life measures
  • The results of these studies could be of significant clinical and psychological importance when recommending the extent of surgery in patients with low-risk DTC
• References:
  • Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2016 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: The American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid 26:1–133
  • Xu S, Huang Y, Huang H, Zhang X, Qian J, Wang X, Xu Z, Liu S, Liu J 2021 Optimal serum thyroid-stimulating hormone level for patients with papillary thyroid carcinoma after lobectomy. Thyroid. Epub 2021 Dec 31.
  • Merten MM, Foster T, Lyden M, Henry M, Castro MR 2021 Favorable early outcomes with thyroid lobectomy for low-risk papillary thyroid cancer: the Mayo Clinic experience. Am Surg 87:1374–1378.
  • Vargas-Pinto S, Romeri-Arenas MA 2019 Lobectomy compared to total thyroidectomy for low-risk papillary thyroid cancer: A systematic review J Surg Res 242:244–251.
  • Verloop M, Louwerens M, Schoones JW, Kievit SJ, Smit JWA, Dekkers OM 2012 Risk of hypothyroidism following hemithyroidectomy: Systematic review and meta-analysis of prognostic studies. J Clin Endocrinol Metab 97:2243–2455.
  • Park S, Jeon MJ, Song E, Oh H-S, Kim M, Kwon H, et al. 2017 Clinical features of early and late postoperative hypothyroidism after lobectomy. J Clin Endocrinol Metab 102:1317–1324.7. Fiore E, Vitti P 2012 Serum TSH and risk of papillary thyroid cancer in nodular thyroid disease J Clin Endocrinol Metab 97:1134–1145.
  • Park JH, Lee YM, Lee YH, Hong SJ, Yoon JH 2018 The prognostic value of serum thyroid-stimulating hormone level post-lobectomy in low- and intermediate-risk papillary thyroid carcinoma. J Surg Oncol 118:390–396.
  • Park S, Kim WG, Han M, Jeon MJ, Kwon H, Kim M, et al. 2017 Thyrotropin suppressive therapy for low-risk small thyroid cancer: A propensity score-matched cohort study. Thyroid 27:1164–1170.
  • Lee MC, Kim MJ, Choi HS, Cho SW, Lee GH, Park YJ, Park DJ 2019 Postoperative thyroid-stimulating hormone levels did not affect recurrence after thyroid lobectomy in patients with papillary thyroid cancer. Endocrinol Metab (Seoul) 34:150–157.

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #CancerSurgeon #SurgicalOncologist #HeadandNeckSurgeon #ThyroidCancer #PTC #Levothyroixine

• In the workup of patients presenting with a goiter, the clinician most address the following three important issues:
  • The existence or the potential development of airway compression
  • The risk of malignancy
  • The presence of hyperthyroidism
• The presence of preoperative shortness of breath:
  • Correlates with goiter size:
    • But it is of limited value as a screening tool for tracheal abnormalities
• Dysphagia correlates with radiographic findings of esophageal deviation and compression:
  • In the absence of dysphagia:
    • Patients do not require further esophageal imaging
• Symptomatic assessment of voice:
  • Does not predict objective findings in patients with goiter and should not replace the laryngeal exam
• Flow volume loop studies most accurately document airway obstruction in the setting of significant airway compression:
  • However, they correlate poorly with goiter weight and upper airway symptoms:
    • I do not recommend flow volume loop studies as part of the routine work-up for patients with goiter
  • Thus, symptomatic flow volume loop and plain film assessment of goiter is insensitive, in distinction to axial CT scanning
  • The finding of tracheal compression on axial CT scanning correlates significantly with the presence of shortness of breath:
    • CT scan tracheal compression to be an appropriate surgical indication given its symptomatic respiratory correlate
• Work up of benign goiter:
  • History and physical examination:
    • Symptomatic
    • Massive goiter
    • Bilateral circumferential goiter
    • Suspect substernal goiter
    • Suspect cancer (vocal cord paralysis, lymphadenopathy)
• Thyroid function tests
• Chest radiograph if suspect cancer:
  • Chest radiograph showing airway deviation → axial CT or MRI

#Arrangoiz #ThyroidSurgeon #CancerSurgeon #ThyroidExpert #EndocrineSurgery #HeadandNeckSurgery #MultinodularGoiter #Goiter #SubsternalGoiter #MountSinaiMedicalCenter

• Extent of Surgery
  • Decisions regarding the extent of surgery:
    • Relate to the balance between operative complications and the risk of recurrence
  • Some suggest total thyroidectomy for goiter:
    • Others recommend a more conservative initial surgical plan
    • Some, such as Kraimps, support a selectively aggressive surgical treatment plan based on extent of disease
• Complication rates must be kept extremely low in the setting of treatment of benign thyroid disease:
  • Therefore, I suggest a conservative philosophy:
    • Tailoring the extent of surgery to the initial disease with the minimum procedure being:
      • A total unilateral lobar resection:
        • Reserving bilateral surgery for significant bilateral goiter
• Studies looking at the extent of surgery and benign multinodular goiter recurrence are confounded by several factors:
  • Variability in the initial extent of thyroid gland nodularity
  • Variability in the extent of recognition of contralateral nodularity at first surgery
  • Insufficient follow-up periods in many studies
  • Variable definitions of recurrence:
    • Some studies, for example, diagnose recurrence based on an asymptomatic, ultrasonographic identification of thyroid nodularity
    • A more reasonable definition of recurrence is the development of:
      • Clinical, palpable thyroid enlargement:
        • Which again meets surgical criteria for goiter treatment
• The question is, can less than total thyroidectomy and even hemithyroidectomy:
  • Be performed if anodular normal tissue is left?
• Complication rates of bilateral surgery are expected to be higher than unilateral
• Conservative initial surgery also allows a patient to avoid a lifetime of replacement therapy
• However, long-term studies show the overall recurrence rate after surgery for goiter:
  • Is in the range of 15% to 42%
• When recurrence occurs and requires revision goiter surgery:
  • The complication rates are significantly higher than for first-time surgery:
    • With RLN rates of paralysis ranging from:
      • 3% to 18%
    • Permanent hyperparathyroidism ranging from:
      • 0% to 25%
• The literature offers conflicting conclusions on factors associated with recurrence of goiter:
  • The duration of postoperative follow-up is important to consider when examining recurrence of goiter
  • The data offered by Delbridge, Guinea, and Reeve suggest recurrences:
    • May require 10 to 13 years to manifest
  • Rojdmark and Jarhult found that the overall recurrence rate rose to:
    • 42% with 30-year postoperative follow-up
  • Bistrup et al., in a randomized, prospective, non-placebo, controlled study, showed rates of recurrence for nontoxic goiter between:
    • 14% and 22%
    • They found the extent of surgery did not relate to the likelihood of recurrence
  • Hegedus, Nygaard, and Hansen found that the weight of thyroid tissue resected was actually greater in those patients who developed subsequent recurrence
  • However, Berghout et al., with a 7-year follow-up:
    • Found that unilateral surgery was associated with higher recurrence rates than bilateral surgery
  • Australian workers have shown that in patients with unilateral disease:
    • Hemithyroidectomy results in a 12% recurrence rate in the contralateral lobe
• Other workers have supported a philosophy of total thyroidectomy or bilateral subtotal thyroidectomy in most patients with goiter
  • Subtotal thyroidectomy is defined as:
    • Total lobectomy with a contralateral remnant approximately equivalent to a small normal lobe
  • Near total thyroidectomy is defined as:
    • A remnant of several grams is maintained in the contralateral bed typically adjacent to the RLN entry point
• In patients who require bilateral surgery:
  • The technique of subtotal lobectomy has been both recommended and condemned:
    • Cohen-Kerem, in a study of 124 patients with a follow-up of 7.6 years, noted that with bilateral subtotal technique:
      • Only 4% of patients required additional surgery
    • Pappalardo found similar rates of recurrence in 69 patients treated for benign goiter randomized to total versus subtotal procedures
    • Reeve et al., however, found subtotal thyroidectomy was associated with a 23% recurrence rate
• Clearly, less than lobectomy as a minimum procedure is unwise:
  • Cohen-Kerem et al. found a recurrence rate after unilateral subtotal resection was 60%
  • Kocher noted an 18% recurrence rate with nodule enucleation
• Kraimps, using a selectively aggressive surgical treatment plan based on the extent of disease, noted very low recurrence rates of 1% with lobectomy and 3% with bilateral surgery:
  • Others have supported such a selectively aggressive approach to surgery based on extent of disease
• Modern series show that in skilled hands:
  • Total thyroidectomy for goiter can be performed without significant complications, given the work of Reeve et al., Netterville et al., and others
  • Delbridge, Guinea, and Reeve noted that for patients with bilateral multinodular goiter, total thyroidectomy:
    • Can be associated with permanent paralysis of the RLN in 0.5% and permanent hypoparathyroidism in 0.4%
    • They believe the policy of autotransplantation of at least one parathyroid during each total thyroidectomy is in part responsible for the low rate of hypoparathyroidism
  • Grant, in his commentary of this article, wrote, “to consider total thyroidectomy as the only acceptable alternative would probably risk causing more cases of troublesome hypoparathyroidism than it would prevent cases of goiter recurrence:
    • Moreover, it seems difficult to assert total thyroidectomy as the only option for benign disease when many surgical authorities strongly disagree with its use, even in thyroid cancer
  • Some workers have suggested that the likelihood of identifying cancer in goiter specimens justifies total thyroidectomy:
    • Most studies document an incidence of malignancy in such specimens of between 3% and 17%:
      • Most are small, occult, incidentally noted malignancies within otherwise benign multinodular goiters and would not normally justify an aggressive surgical approach
• Berghout et al., has suggested a greater likelihood of recurrence in females and in patients with a positive family history of thyroid disease:
  • Overall, females were found to be three times more likely to require revision surgery
  • Those with a positive family history of thyroid disease were six times more likely to require revision surgery:
    • Others have found no such increased risk in these populations
      • I tend to be more aggressive in females and in those with a positive family history:
      • Especially if they are young
• Summary of the extent of Surgery for Goiter:
  • Complication rates must be low in the setting of surgery for benign thyroid disease
  • Less than unilateral lobectomy leads to extremely high recurrence rates and difficult reoperations and is to be condemned
  • The extent of surgery should be rationally tailored to the extent of initial disease
  • Dominant goitrous enlargement should be treated with total lobectomy on that side
  • Preoperative assessment with imaging will help to document the extent of surgery necessary on the contralateral side:
    • With clear-cut unilateral disease, total lobectomy is appropriate
    • With clear-cut evidence of bilateral goiter, bilateral surgery is appropriate
  • Consideration should be given for more aggressive surgery in young females and in patients with a positive family history of thyroid disease who may have a higher recurrence rate
  • In patients who have required multiple thyroid surgeries for benign recurrence and still have some remnant tissue remaining after the last revision surgery, radioactive iodine ablation can be considered
• Hashimoto’s Thyroiditis:
  • Other variables important during surgery are:
    • The degree of capsular blood vessel engorgement and friability, and goiter consistency
  • Goiters that are soft and compressible are more easily manipulated during surgery, whereas those that are firm can be challenging even when of small size
  • Generally, glands affected by Hashimoto’s thyroiditis are more difficult to work on than the more typical benign adenomatous goiter
  • Hashimoto’s glands, especially those resulting from the fibrotic variant of Hashimoto’s thyroiditis:
    • Can be firm and less compressible and have a friable, “sticky” surface, which bleeds easily
    • Such goiters can be associated with multiple perithyroidal lymph nodes that can sometimes make a surgeon consider papillary carcinoma
    • Such nodes also make parathyroid identification more challenging
    • The rare fibrous variant of Hashimoto’s thyroiditis is an especially firm variant:
      • Which makes the performance of less than total lobectomy challenging

#Arrangoiz #ThyroidSurgeon #CancerSurgeon #ThyroidExpert #HeadandNeckSurgeon #SurgicalOncologist #MultinodularGoiter #Goiter #SubsternalGoiter #CASO #CenterforAdvancedSurgicalOncology

• The ACOSOG Z1071 trial:
  • Was designed to determine the false negative rate (FNR) of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) in women initially presenting with cN1 disease
  • The trial enrolled women from 136 institutions who had:
    • Clinical T0 through T4, N1 through N2, M0 breast cancer who received neoadjuvant chemotherapy
  • Patients enrolled had pre-chemotherapy axillary nodal disease confirmed by fine-needle aspiration or core needle biopsy
  • Following NAC:
    • Patients underwent both SLNB, followed by a back-up axillary lymph node dissection
  • SLNB with dual tracer using both blue dye (isosulfan blue or methylene blue) and a radiolabeled colloid mapping agent was encouraged
  • Rates of detection of at least one SLN were 92.9% in patients with cN1 disease and 89.5% in patients with cN2 disease
  • Overall, the FNR of SLNB after NAC was 12.6%
  • Bivariable analyses found that the likelihood of a false-negative SLN finding was significantly decreased when:
    • The mapping was performed with the combination of blue dye and radiolabeled colloid:
      • P=.05; FNR, 10.8% combination vs 20.3% single agent
    • By removal of at least 3 SLNs:
      • P=.007; FNR, 9.1% for ≥ 3 SLNs vs 21.1% for two
  • A clip was placed at initial node biopsy prior to NAC in 203 patients:
    • In the 170 (83.7%) patients with cN1 disease and at least two SLNs resected, clip location was confirmed in 141 cases
    • In 107 (75.9%) patients where the clipped node was within the SLN specimen, the FNR was 6.8% (confidence interval [CI]: 1.9%-16.5%)
    • If the clipped node was found in the ALND specimen, the FNR was 19.0% (CI: 5.4%-41.9%)
    • In cases where a clip was not placed (n = 355) and in those where the clipped node location was not confirmed at surgery (n = 29):
      • The FNR was 13.4% and 14.3%, respectively
    • While the FNR overall exceeded the 10% threshold considered to be clinically acceptable:
      • The authors concluded that with modifications to the SLN technique (i.e., dual tracer mapping and retrieval of at least 3 negative SLNs), to the FNR was < 10% and supported the use of SLN surgery as an alternative to axillary lymph node dissection in this patient population
  • Subsequently, Caudle et al have reported a separate registry of 191 patients and showed that removing the clipped positive node in addition to SLN:
    • Had an FNR as low as 2.0%
• References
  • Boughey JC, Suman VJ, Mittendorf EA, Ahrendt GM, Wilke LG, Taback B, et al.; Alliance for Clinical Trials in Oncology. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013;310(14):1455-1461.
  • Boughey JC, Ballman KV, Le-Petross HT, McCall LM, Mittendorf EA, Ahrendt GM, et al. Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 2016;263(4):802-807.
  • Caudle AS, Yang WT, Krishnamurthy S, Mittendorf EA, Black DM, Gilcrease MZ, et al. Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection. J Clin Oncol. 2016;34(10):1072-1078.

• The presence of goiter was originally determined from autopsy studies that weighed the thyroid gland, but this was superseded by the use of ultrasound by which a goiter is diagnosed if:
  • The size of the thyroid gland is greater than three standard deviations of the median:
    • Volume 18 ml for women and 25 ml for men
• Goiter is more common in iodine-deficient regions of the world:
  • Where endemic goitre affects 10% of the population
• In Framingham:
  • Clinically apparent nodules (palpation) were present in:
    • 6.4% of women and 1.5% of men:
      • The presence of single thyroid nodules was 3%, and multinodular goiter was 1%
• In an autopsy study in 1955:
  • 50% of people had thyroid nodules and the majority were multiple
• Like autopsy, imaging frequently reveals subclinical thyroid nodules and, when ultrasound is used in epidemiological studies:
  • The estimate of goiter prevalence is 19% to 67%
• Incidental thyroid nodules are seen in up to:
  • 25% of contrast-enhanced chest CT scans
  • 16% to 18% of CT and MR scans of the neck
  • 1% to 2% PET scans
• In patients under 40 years:
  • The goiter is typically a solitary nodule,
• Whereas diffuse goitrer is more common over the age of 65 years
• The female to male ratio is:
  • 4:1

• Patients present with a painless lump and are often unsure as to its duration:
  • The increased size of the goiter can lead to symptoms related to pressure effects on adjacent structures such as:
    • Dysphagia (from pharyngeal and/or esophageal compression)
    • Globus sensation
    • Hoarseness (from laryngeal or recurrent laryngeal nerve compression)
    • Shortness of breath (from tracheal deviation and compression)
• An incidental thyroid nodule (ITN) is one of the most common incidental findings on imaging studies that include the neck:
  • Guidelines have been developed to assist the medical provider in deciding when and how to investigate ITN

• The overall significant complication rate from sentinel lymph node dissection reported from the ACOSOG Z0010 trial:
  • Was low, with 32% of patients reporting at least one surgical side effect and less than 1% of patients requiring hospitalization
  • The most common surgical side effect was axillary paresthesia:
    • Affecting 307 (8.6%) of 3,573 patients
  • Allergic reaction was reported in less than 1% related to the administration of lymphazurin blue dye
  • Lymphedema in 7%
  • Brachial plexus injury in less than 1% of patients
  • Only one anaphylactic reaction to blue dye was reported
• References
  • Hunt KK, Ballman KV, McCall LM, Boughey JC, Mittendorf EA, Cox CE, et al. Factors associated with local-regional recurrence after a negative sentinel node dissection: results of the ACOSOG Z0010 trial. Ann Surg. 2012;256(3):428-436.
  • Boughey JC, Hunt KK. The ACOSOG experience. In: Kuerer HM, ed. Kuerer’s Breast Surgical Oncology. New York, NY: McGraw-Hill Companies; 2010:517-530.

#Arrangoiz #BreastSurgeon #BreastCancer #SurgicalOncologist #CancerSurgeon #SLNB #SentinelLymphNodeBiopsy

• Active transport of iodine (I-) into the thyroid follicular cells:
  • Is mediated by the Na/I symporter (NIS)
• Intracellular accumulated iodide ion is then passively translocated across the apical membrane into the colloid:
  • Via pendrin proteins and Cl channels
• The effluxed iodide ion becomes covalently attached to thyroglobulin:
  • Mediated by thyroperoxidase (TPO)
• Further iodinization of tyrosine molecules on the thyroglobulin glycoprotein then occurs via TPO forming:
  • Monoiodotyrosines (MIT) and diiodotyrosines (DIT):
    • Which are then coupled to create the bioactive thyroid hormones T4 and T3:
      • Again catalyzed via TPO
• Colloid is taken up into the follicular cell by:
  • Micropinocytosis
• Through digestion of this thyroglobulin by:
  • Lysosomal extracts and a resulting proteolytic breakdown of the thyroglobulin:
    • T4 and T3 are released into the cytoplasm
• Finally T4 and T3 are transported into the circulation by a hormone transporter:
  • Monocarboxylate transporter 8 (MCT8)

#Arrangoiz #ThyroidSurgeon #CancerSurgeon #HeadandNeckSurgeon #EndocrineSurgeon #ThyroidHormone

• The 21-gene recurrence-score assay (e.g., Oncotype DX, Genomic Health):
  • Is one of several commercially available gene-expression assays:
    • That provide prognostic information in hormone-receptor-positive breast cancer
• The assay originally set cut points for:
  • Low risk at a recurrence score < 18
  • Intermediate risk at 18 to 30
  • High risk at > 31
• It is predictive of chemotherapy benefit when:
  • The recurrence score (RS) is high (> 26), and prognostic for very low rates of distant recurrence (2% at 10 years) when the RS is low (< 10)
• The TAILORx prospective randomized clinical trial:
  • Was completed to determine whether chemotherapy is beneficial for women:
    • With an intermediate RS of 11 to 25
  • The cutoffs for this trial were adjusted to ensure all patients in the intermediate range who may benefit were included
  • At 9 years of follow-up:
    • The endocrine therapy only and the chemo-endocrine therapy group:
      • Had similar rates of invasive disease-free survival:
        • 83.3% vs. 84.3% respectively
    • The endocrine therapy alone was noninferior to chemoendocrine therapy for all patients in the intermediate RS study group
    • The two groups also had similar outcomes in freedom from disease recurrence at a distant or locoregional sites
    • However, the chemotherapy benefit for invasive disease-free survival varied with the combination of recurrence score and age (P=0.004):
      • With some benefit of chemotherapy found in women 50 years old or younger with an RS of 16 to 25
      • In women less than 50 receiving chemotherapy demonstrated a lower rate of distant recurrence than endocrine therapy if RS was 16 to 20 (percentage-point difference, 0.8 at 5 years and 1.6 at 9 years) or 21 to 25 (percentage-point difference, 3.2 at 5 years and 6.5 at 9 years)
      • Overall survival however remained similar
  • For this reason, researchers conclude that the 21-gene assay can identify women with ER postive early-stage breast cancer:
    •  Who may be spared chemotherapy if they are over 50 years old with an RS of 25 or lower, as well as women 50 years or younger with RS of 15 or lower
• References
  • Sparano JA, Gray RJ, Makower DF, Pritchard K, Albain KS, Hayes DF, et al. Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med. 2018;379(2):111-121.

#Arrangoiz #BreastCancer #BreastSurgeon #OncotypeDx #SurgicalOncologist #21GeneRecurrenceScoreAssay #CancerSurgeon