Endocrine Surgery News

Endocrine Surgery News

British Association of Endocrine & Thyroid Surgeons Annual Scientific Conference

Mr Lynn and Dr Drury (Mrs Lynn) attended the British Association of Endocrine & Thyroid Surgeons Annual Scientific Conference, which was held in Liverpool, UK from 9-10 October 2014.

A National Analysis Of Thyroid And Parathyroid Surgery Using Hospital Episode Statistics Data Linkage

S. A. R. Nouraei, S. E. Middleton, H. Kaddour, K. Ghufoor, N. S. Tolley

Aim: to obtain a more complete picture of the outcome of thyroid and parathyroid surgery using bespoke Hospital Episode Statistics data linkage.

Records were obtained for patients undergoing thyroid and parathyroid  surgery between 2004-2012.

There were 18 931 males and 77 715 females with a mean age of 52 ± 28 years. 75 039 thyroidectomies and 24 234 parathyroidectomies were performed. There were 439 cases of vocal cord palsies, 264 cases of airway compromise and 272 tracheostomies were inserted.

Conclusions: Using hospital episode statistics data linkage is complicated but provides a more accurate and comprehensive picture of clinical activity, treatment pathways and surgical complications.

Comment: It is recognized that although tracheostomies are quite rare, it is a well recognized complication. It is essential that the patient is warned of this prior to surgery.   


Do Intra-Operative Changes To Recurrent Laryngeal Nerve Electromyography During Thyroid Surgery Predict Post-Operative Neuropraxia?

O. R. Hughes, S. Ilfecho, G. Mochloulis

Aim: To determine whether intra-operative nerve monitoring can be used as a method of predicting recurrent laryngeal nerve (RLN).

In a population study of 140 patients (113F/27M) 29% were undergoing total thyroidectomies with the remainder undergoing hemithyroidectomies. The RLN neuropraxia rate was 11%. The mean time for gland excision was 16.18 minutes (SD 5.93) for patients with normal vocal cord function post-operatively compared with those with RLN neuropraxia which took 33 minutes (SD 17.64).

The mean time RLN EMG latency for normal patien was was 2.19 (SD 3.13) compared with those with RLN neuropraxia which was 4.29 minutes (SD 12.24).

Conclusions: In this study, the time taken to excise the thyroid gland seems to be a more accurate predictor of post-operative RLN neuropraxia rather than the use of EMG abnormalities.

Comment: This shows that there are problems with recurrent laryngeal nerve paresis even with modern technology but the study is so small, it is unable to show a statistical significance with nerve monitoring.


Does Minimally Invasive Parathyroidectomy Improve Cosmetic Outcome?

P. Truran, E. Thompson, H. Nightingale, R. D. Bliss, S. R. Aspinall, T. W. J. Lennard

Aim: to determine whether minimally invasive parathyroidectomy (MIP) provides a better cosmetic outcome and to examine if there are any other factors that may influence this outcome.

Overall, 152 patients rated their scar appearance as either good or excellent. Mean scar length was shorter in the MIP group (2.9 cm vs. 5.8 cm, p<0.001). Performance of logistic regression, younger age and female gender was associated with poorer score with respect to scar consciousness and scar appearance.

Conclusions: mature scars after MIP have an excellent cosmetic outcome. Younger age and the female gender are associated with poor satisfaction and cosmetic outcome.

Comment: This study shows no great difference between minimally invasive surgery and a normal cervicotomy however our own view is that it does give a better cosmetic result.


Intra-Operative Recurrent Laryngeal Nerve Monitoring In Thyroid Surgery

N. Ranga, P. Baruah, C. Spinou

Aim: to assess the use of intra-operative nerve monitoring (IONM) to determine the integrity of recurrent laryngeal nerve (RLN) during thyroid surgery.

Out of 80 patients, IONM was used in 54 cases (67%). The incidence of RLN nerve palsy in this group was 5 cases (9%) while it was 3.8% (1 in 28 cases) in the non-monitored group).

Conclusions: IONM is safe in thyroid surgery however the results of the study do not show any significant difference in the incidence of RLN palsy in patients who underwent IONM compared to those who did not.


Effectiveness Of Preventative And Other Surgical Measures On Hypocalcaemia Following Bilateral Thyroid Surgery: A Systematic Review And Meta-Analysis

R. Antakia, O. Edafe, L. Uttley, S. P. Balasubramanian

Aim: to conduct a review and meta-analysis of preventative and other surgical measures on post-thyroidectomy hypocalcaemia as it is considered to be a common surgical risk fact associated with short and long term morbidity.

Conclusions: Searches of PubMed, EMBASE and Cochrane databases identified that post-operative supplementation with calcium and vitamin D has been effective in preventing hypocalcaemia.


Laryngeal Reinnervation In The Treatment Of Unilateral And Bilateral Vocal Cord Palsy: Introducing These Techniques Into The UK

K. Heathcote, M. Birchall, Y. Karagama, J. P. Marie

Aim: to determine the best outcome of recurrent laryngeal nerve palsy (RLNP) following thyroidectomy surgery.

RLNP results in voice deterioration and bilateral RLNP airway compromise may require tracheostomy intervention. The best outcome is usually achieved through early rehabilitation using thyroplasty or injection augmentation. It has become standard practice to offer laryngeal reinnervation in France and USA.

In unilateral cases, laryngeal reinnervation has been shown to restore phonatory function to normal or near normal and these results are currently being compared to a randomized control with thyroplasty.

Conclusions: Surgeons in the UK are being trained to perform largneal reinnervation and this should be considered for patients in the UK with RLNP.

Comment: This work has shown to be remarkable in the improvement of reinnovation techniques after bilateral recurrent laryngeal nerve palsy. We look with interest on their further studies and presentations.


Re-Operative Parathyroidectomy: Patterns Of Persistence In Patients Presenting To A Tertiary Referral Centre

C. M. McIntytre, J. L. Y. Allen, V. A. Constantinides, K. Nastos, I. Christakis, N. Tolley, F. F. Palazzo

Aim: To identify the patterns of disease that are more likely to be missed during the initial operation.

Conclusions: Re-operative parathyroid surgery is tricky and must only be performed after reconsideration of the initial diagnosis and the pathology must be as localized as possible. The glands more commonly missed during the initial operation were descended superior and ectopic glands in this study.

Comment: This report has emphasized how important it is for re-operative parathyroid cases to be performed in a centre of excellence with high case volume. Our own results of over 90 cases showed only 1 failure to cure in patients with one or more previous operations.


Thyroid Ultrasound – The Time Has Come For Specialist Radiology

A. Ward, A. Light, P. Truran, S. Aspinall

The British Thyroid Association (BTA) guidelines 2014 stipulate the need for fine needle aspiration cytology (FNAC) for the management of thyroid cancer.

Aim: To audit reporting of thyroid ultrasound in two Trusts (Trust 1, Trust 2) in the Northern Deanery to determine whether the BTA guidelines are being followed.

Trust 1 had employed radiologists with a special interest in thyroid while Trust 2 did not. Reports were audited in reference to completeness of information on the features associated with thyroid malignancy. These included echogenicity, geneity, consistency, margins, presence of calcification, halo, lymph nodes and risk stratification.

Conclusions: There was a statically significant difference between the two Trusts in risk stratification and commenting on the cervical lymphadenopathy. It is suggested that if the BTA guidelines are to be followed then thyroid ultrasound will have to be performed by specialist radiologists to accurately risk stratify thyroid nodules for malignancy.


The Role Of Intra-Operative Nerve Monitoring In Reducing The Risk Of Recurrent Laryngeal Nerve Injury During Thyroid Surgery: A Systematic Review And Meta-Analysis

R. Antakia, N. Antakia, B. McWilliams

Aim: To assess the role of intra-operative nerve monitoring (IONM) during thyroid and parathyroid surgery in reducing the incidence rate of laryngeal nerve injury.

Conclusions: This study has shown that IONM can aid the reduction of rates of recurrent laryngeal nerve injury in both primary and revision thyroid surgery.

Comment: This is a good study but shows small participation volume. As a result it is not possible at the moment with intraoperative nerve monitoring to prove dogmatically that it reduces the incidence of long term nerve paralysis (due to studies of small volume).


Hypercalcaemia Following Alfacalcidol For Post-Surgical Hypoparathyroidism – An Underestimated Complication?

C. Leng, G. Charlesworth, E. Nofal, S. Balasubramanian

Aim: To determine the incidence of hypercalcaemia in patients treated with Alfacalcidol for post-surgical hypocalcaemia and explore the factors relating to this complication.

Conclusions: In this study, the risk of Alfacalcidol induced hypercalcaemia in patients with post-surgical hypoparathyroidism is higher than the risk of this complication in a non-surgical setting. Regular monitoring of serum calcium is advised with an attempt to gradually withdraw vitamin D supplements for all patients on Alfacalcidol for post-surgical hypoparathyroidism.

Comment: This emphasizes how important it is for patients post-operatively on Alfacalcidol and calcium supplements to be watched carefully. These drugs should be considered to be like insulin and it is very easy to over treat and have iatrogenic hypercalcaemia.   



38th Annual Meeting of the European Thyroid Association

Mr Lynn and Dr Drury (Mrs Lynn) attended the 38th Annual Meeting of the European Thyroid Association, which was held in Santiago de Compostela, Spain from 6-10 September 2014. The following articles are summaries of those that were of particular interest. 


Efficacy And Toxicity Of Vandetanib For Advanced Medullary Thyroid Cancer Treatment, The French Experience

Cecile Chougnet, Martin Schlumberger, Borget Isabelle, TUTHYREF Network 

Vandetanib has been shown to be effective treatment against medullary thyroid cancer but may have associated toxicities.

Aim: To determine the toxicity profile and response rate of vandetanib.

Results from 60 patients who had vandetanib treatment from 2010-2012 were analysed. 93% had metastatic disease and the remainder had locally advanced disease. Duration of treatment ranged from 0.3-36 months with the median being 10 months. All patients had at least one adverse effect during treatment with the most common effects being skin toxicity, diarrhea and asthenia. 16 patients discontinued treatment due to toxicity.

Conclusions: Vandetanib is an effective treatment option for patients with medullary thyroid cancer but need to be monitored carefully to manage adverse effects of the drug.


Medullary Thyroid Cancer & Anaplastic Carcinoma

Mild Hypercalcitoninemia In Patients With Benign Disease Of The Thyroid And Calcium Homeostasis

Juergen Kratzsch, Stefan Karger, Friedhelm Raue, Joachim Feldkamp, Sandra Scheel, Tanja Diana, Nina Mattheis, George J. Kahaly

Calcitonin is an effective diagnostic and therapeutic biomarker for monitoring patients with medullary thyroid cancer.

Aim: To evaluate a novel immunoassay which can be used to measure the calcitonin in serum from patients with various benign thyroid disease.

The upper reference limit was defined at 6.40 pg/mL and 9.52 pg/mL for healthy females and males respectively. The maximal concentrations of calcitonin in patients with Graves disease, Hashimoto’s thyroiditis, non-Graves hyperthyroidism and diseases relating to calcium homeostasis were measured at 19.9, 10.1. 13.3 and 19.1 pg/mL respectively.

Conclusions: Comparison of values of healthy subjects with those of benign diseases of the thyroid and calcium homeostasis may result in a diagnosis of mild hypercalcitoninemia. It is important to consider the detailed clinical history of patients to determine the correct interpretation of results.


Reference Range Of Serum Calcitonin In Children

Maria Grazia  Castagna, Laura Fugazzola, Fabio Maino, Danila Covelli, Fausta Sestini, Chiara Ferraris Fusarini, Carlo Scapellato, Francesco Macchini, Gabriele Cevenini, Furio Pacini

Aim: To establish the serum calcitonin reference range in newborns and children up to 16 years of age.

Conclusions: Serum calcitonin levels progressively decrease during the first 3 years of life. After this, serum levels are comparable with those of adults. This information may be helpful when screening for RET proto-oncogene mutations in children of a young age. 


Thyroid Cancer Diagnostics

Locally Invasive Papillary Thyroid Carcinoma Involving A Functioning Recurrent Laryngeal Nerve Exclusively May Be Treated By Shaving Technique With Macroscopic Residual Tumor Followed By High-Dose Radioiodine Therapy

Hyoung Shin Lee, Kang Dae    Lee, Jun Woong Song, Gi Yun Nam, Sung Won Kim, Seon Mi Baek, Hyo Sang Park

Aim: To determine the feasibility of employing a shaving technique to preserve the recurrent laryngeal nerve (RLN) involved in papillary thyroid carcinoma (PTC) cases, followed by a high dose of radioactive iodine.

This was a retrospective study involving 41 patients with no distinguishing lifestyle or treatment factors. They were split into group A (resected RLN n=19) and B (preserved RLN n=22). The mean dose of radioactive iodine was 245.0±140.3 mCi (range 100-740 mCi). Permanent post-operative vocal cord paralysis occurred in 2 patients in group B (10.5%). Overall recurrence rate o disease was 26.3% in group A (5/19) and 27.3% in group B (6/22) with no deaths due to PTC during the follow-up period (range 36-150 months).

Conclusions: Patients with locally invasive PTC involving the RLN may be treated by using a shaving technique with subsequent high dose radioactive iodine treatment.


Is It Enough To Perform FNAB From Dominant Nodule?

Omer Engin, Volkan Tekin, Mehmet Yilmaz, Enis Unluturk, Ulas Urganci

Aim: To investigate from which nodule is it best for FNAB to be performed and whether it is sufficient to only perform FNAB on the dominant nodule.

315 who underwent bilateral total thyroidectomy surgery for thyroid cancer between 2007-2014 were included in this study.

Looking at dominant nodules, 173 were benign and the remaining were classed as malignant. The average malignant nodule was 14.35 (1-80) mm. In 142 cases, the size of the malignant nodule was less than 8 mm.

Conclusions:  FNAB is ineffective for nodules smaller than 8 mm due to technical difficulties. FNAB should not only be performed on the dominant nodule, as over half of the dominant nodules in this study were benign. The histopathology of one nodule does not reflect the whole thyroid tissue so FNAB is advised on all nodules that are accessible and greater than 8 mm. 



Nature And Prevalence Of Pregnancy Associated Thyrotoxicosis

Akane Ide, Nobuyuki Amino, Takumi Kudo, Shino Kang, Waka Yoshioka, Mako Fujiwara, Eijun Nishihara, Mitsuru Ito, Hirotoshi Nakamura, Akira Miyauchi 

Aim: To investigate the prevalence of pregnancy induced Graves’ disease

Human chorionic gonadotropin (hCG) can lead to gestational thyrotoxicosis, Graves’ thyrotoxicosis and postpartum destructive thyrotoxicosis. 

This was a retrospective review of 1,197 (1,011F/186M) non-treated patients with thyrotoxicosis from Jan-Dec 2013 at the outpatient clinic in Japan. 

Conclusions: A significant number of women develop Graves’ disease postpartum. The prevalence of pregnancy induced Graves’ disease was much less than that of developing Graves’ disease postpartum or gestational thyrotoxicosis. 


Hyperthyroidism And Orbitopathy

Diagnosis And Management Of Graves’ Disease In Europe – Results Of A Survey Among Members Of The European Thyroid Association (ETA)

Luigi Bartalena, Henry B. Burch, George J. Kahaly

Aim: To compare treatment methods of Graves’ disease within Europe and North America.

The majority requested free T4 (82%) and TSH (81%) measurements for a diagnosis of hyperthyroidism. Free (61%) and total T3 (14%) were less commonly requested. The use of ultrasound (71%) was more common than scanning (33%). Antithyroid drugs (84%), radioactive iodine (14%) and thyroidectomy (2%) were used as the first-line treatment for uncomplicated cases.

In cases where women were planning to become pregnant, 30% of respondents were advised surgical intervention, 10% advised radioactive iodine treatment and the remainder suggested antithyroid drugs.

During pregnancy, 76% of respondents used propylthiouracil during the first trimester and then switched to methimazole/carbimazole (59%).

Conclusions: There are still significant differences in diagnostic treatment preferences between the two continents. Antithyroid drugs are the first-line treatment for Graves’ disease in Europe while radioactive iodine is the preferred treatment of choice in North American.


Thyroid Cancer Pathogenesis

Estrogen And Progesterone Receptors Expression In Differentiated Thyroid Cancer: A Role In The Risk Stratification Of Thyroid Tumors

Simone De Leo, Michela Perrino, Carla Colombo, Stefania Rossi, Delfina Tosi, Leonardo Vicentini, Gaetano Bulfamante

Aim: To determine whether there is a link between sex hormones and the pathogenesis and development of thyroid tumors.

The expression of estrogen receptor α (ERα) and progesterone receptor (PR) were studied in 190 (146F/44M) patients with thyroid cancer. ERα and PR were significantly correlated tumor size and the presence of metastatic neck lymph nodes. 

Conclusions: Current data show that ERα and PR expression is higher in patients with more aggressive thyroid cancer.  


Clinical Thyroidology

Subclinical Hypothyrodisim And The Risk Of Non-Fatal And Fatal Stroke: An Individual Participant Analysis

Layal Chaker, Christine Baumgartner, Wendy J.P. den Elzen, M. Arfan Ikram, Manuel R. Blum, Stephan J. L. Bakker, Abbas Dehghan, Christiane Drechsler, Robert N. Luben, Albert Hofman, Marileen L.P. Portegies, Marco Medici, Giorgio Iervasi, Tinh-Hai Collet, Alexandra Brenmer, Christoph Wanner, Massimo Iacoviello, Robin P. Dullaart, José A. Sgarbi, Graziano Ceresini, Rudi G. Westendorp, J. Wouter Jukema, Misa Imaizumi, Jayne A. Franklyn, Douglas C. Bauer, Anne R. Cappola, John P. Walsh, Salman Razvi, Kay-Tee Khaw, Henry Völzke, Oscar H. Franco, Jacobijn Gussekloo, Nicolas Rodondi, Robin P. Peeters

Aim: To determine whether there is a correlation between patients with subclinical hypothyroidism and their risk of non-fatal and fatal stroke.

Subclinical hypothyroidism was defined as a TSH level between 4.5-20 mIU/L with a normal free T4 level. In age and sex-adjusted analyses, subclinical hypothyroidism was not significantly associated with an increased risk of non-fatal stroke and fatal stroke events, and mortality. However, those with subclinical hypothyroidism in the age group 18-50 had an increased risk of non-fatal and fatal stroke events. There was also an increased risk of fatal stroke events in the age group 50-65. 

Conclusions: Subclinical hypothyroidism has been shown to be associated with a higher risk of both non-fatal and fatal stroke events in adults between 18-65.


Thyroid Cancer Therapeutics 

Hemithyroidectomy Versus Total Thyroidectomy For Unilateral Papillary Thyroid Microcarcinoma: A Comparative Study

Kang Dae Lee, Hyoung Shin Lee, Jun Woong Song, Sun Won Kim, Jong Chul Hong, Taejung Park 

Aim: To compare the outcomes between hemithyroidiectomy (HT) and total thyroidectomy (TT) in patients with unilateral papillary thyroid microcarcinoma (PTMC).

A retrospective study was conducted with 160 patients who were divided into group A (HT, n=41) and group B (TT, n=119). Recurrence of disease occurred in 3 cases in group A (7.3%) and 5 cases in group B (4.2%).

Conclusions: No significant difference was noted for treatment of PTMC using either a HT or TT surgical approach in this study.


The Impact Of The Number Of Harvested Central Lymph Nodes On The Lymph Node Ratio And Postoperative Athyroglobulinemia

Eun-Jae Chung, Young-Soo Rho

Aim: To determine the impact of lymph node harvest on the lymph node ratio (LNR) and postoperative athyroglobulinemia

This study included 118 patients who underwent a total thyroidectomy and bilateral central lymph node dissection (CND). These patients were all pre-operatively diagnosed with papillary thyroid microcarcinoma by FNAB and had no evidence of central or lateral neck node metastasis.

The mean number of lymph nodes retrieved in the central compartment was 6.5. Those that had a ≥6.5 retrieval had a significantly higher rate of postoperative athyroglobulinemia (38.6% vs. 56.3%). The rate of vocal cord palsy and hypoparathyroidism were unaffected with the number of lymph nodes retrieved.

Conclusions: There is a positive correlation between clearing metastatic nodes in level VI and retrieval of lymph nodes during CND.


Thyroid Cancer Outcome In Children And Young Adults

Marinella Tzanela, Christina Kanaka-Gantenbein, Olga Karapanou, Phoebe Rontogianni, Aikaterini Dacou-Voutetakis, Stylianos Tsagarakis

Aim: To analyze the outcome of thyroid cancer in children and young adults.

This was a retrospective study involving 97 patients (5-20 years old, 21M/76F) over a 20 year time span. A diagnosis of papillary thyroid carcinoma was found in 95.9% of patients. At their final follow-up 76.6% of patients were in remission, defined by a negative 131I scan. Patients that had persistent disease were noted to have a higher prevalence of lymph node metastases at presentation (87.5% vs. 39.1% of patients in remission, p = 0.006) and had received a higher dose of radioactive iodine (104.64±8.6 mCi vs. 79.02±4.6 mCi, p = 0.011).

Conclusions: These results show that lymph node metastases is the most prevalent morbidity factor in children and young adults who have thyroid cancer. Treatment with surgical intervention, radioactive iodine is advised and will result in remission in the majority of cases. 


Ultrasound-Guided Percutaneous Ethanol Ablation Of Selected Metastatic Lymph Nodes Of Differentiated Thyroid Carcinoma

Nikolai Raikov, Diana Vyagova, Svetoslav Todorov, Daniela Malcheva, Snezhana Vicheva, Asya Raykova, Borislav Chaushev, Boyan Nonchev

Aim: To prove that ethanol ablation of single metastatic lymph nodes in differentiated thyroid carcinoma is a viable method of treatment in selected patients.

4 patients (8 laryngeal nerves) were included in this study. Local swelling and laryngeal nerve palsy occurred only in one of the cases (12.5%). Two of the lymph nodes which had been ablated disappeared and the remaining nodes reduced their size by up to 80%.

Conclusions:  Using ethanol ablation to treat selected metastatic lymph nodes is an alternative to surgery as it causes a reduction in size of reduces vascularization in some patients.


Endoscopic Thyroidectomy Via Retro Auricular Approach

Min Woo Park,, Soon-Young Kwon, Jeong-Soo Woo, Seung-Kuk Baek, Jae-Gu Jo, Si-Youn Song, Kwang Kin Jung, Kwang-Yoon Jung

Aim: To evaluate the feasibility and safety of performing an endoscopy thyroidectomy using a retro auricular approach.

45 cases were performed from May to December 2013. The mean age of the patient was 43.7 years. The mean operating time was 152±48 min. The post-operative drainage was 149±90 mL and the mean duration of the drain was 4.6±1.8 days. The post-operative hospital stay was 3.1±1.6 days.

One temporary vocal cord paralysis was observed but hypocalcaemia or facial nerve palsy was not observed post-operatively. The cosmetic outcomes were excellent and all patients were satisfied.

Conclusions: Endoscopy thyroidectomy using a retro auricular approach is a safe and feasible option for patients.


Does Corticosteroid Have Any Beneficial Effect On Voice Change After Thyroidectomy?

Shirzad Masiri, Nassim Sodagari

Aim: To evaluate the effect of a single preoperative dose of steroid on voice change after thyroidectomy.

It has been hypothesised that inflammation and oedema in the surgery site has a major role in voice change after thyroidectomy. Sixty-four patients in a randomized trial were separated into two groups. One group received IV dexamethasone preoperative while the other group received a placebo. Voice change was evaluated by Voice Impairment Score (VI) postoperatively.

VIS was significantly different the first day after surgery between dexamethasone group and the control (5:13’; P=0.0001). A difference was also observed a week after surgery but without statistical significance (1:3; P=0.397). No complications were seen in patients that received dexamethasone.

Conclusions: Preoperative administration of dexamethasone may be useful decreasing voice change after thyroidectomy.


Robotic Thyroidectomy Learning Curve For Beginning Surgeons With Little Or No Experience Of Endoscopy Surgery

Jae Hyun Park, Jandee-Lee, Sang-Wook Kang, Jong Ju Jeong, Kee-Hyun Nam, Keum-Seok Bae, Seong Joon Kang, Woong Youn Chung

Aim: To determine whether using will help robotic surgery shorten the learning curve for fellowship-trained surgery.

This study evaluated the outcomes in 125 patients who underwent robotic thyroidectomy by two recently graduated fellowship-trained surgeons. During the first six month training period, these two surgeons accumulated enough experience to perform conventional open thyroidectomies. During the next six months, they performed robotic thyroidectomies under supervision. Learning curves were analysed by operation time, with proficiency defined as the point at which the slope of the time curve became less steep.

Conclusions: The surgical learning curve for robotic thyroidectomies performed by these graduates with previous little to no experience in endoscopic surgery showed excellent results when comparted to those of more experienced surgeons. Training under the supervision of an experienced surgeon has been shown to shorten the learning curve for robotic thyroid surgery.


Intraoperative Frozen Biopsy For The Evaluation Of Extrathyroidal Extension In Papillary Thyroid Cancer

Byungjoo Lee, Soo Geun Wang, Young Min Park, Junchoon Lee, Inju Kim, Dong Hoon Shin, Seok-Man Son

Aim: To examine extrathyroidal tumour extension through pathological analysis to determine the clinical usefulness of frozen biopsy for intraoperative decision making in patients with papillary thyroid cancer (PTC).

268 patients who were diagnosed with PTC between March 2013 and May 2013 were enrolled in the study.   

Extrathyroidal extension was confirmed in 54 patients (20%) on biopsy. On pathological examination, extra thyroidal extension was confirmed in 80 patients (30%).

Conclusions: intraoperative frozen biopsy is a useful tool in identifying the presence of extrathyroidal extension. It is also useful in assisting the surgeon to the extent of the surgery and central neck dissection required in patients with PTC.  


Papillary Thyroid Carcinoma In Children And Adolescents – A 34-Year Experience In 227 Patients

Kiminori Sugino, Mitsuji Nagahama, Wataru Kitagawa, Hiroshi Shibuya, Keiko Ohkuwa, Takashi Uruno, Akifumi Suzuki, Junko Akaishi, Chie Masaki, Koichi Ito

Aim: To analyse clinical features and outcomes of papillary thyroid carcinoma (PTC) in paediatric and adolescent populations in Ito Hospital, Japan.

227 (201F/26M) patients were involved in this study. They were 20 years or younger and underwent surgery between 1979 and 2012. The mean age at diagnosis was 18 years (range 7-20 years).

Two patients died from the disease and 45 patients had recurrent disease. The
10-year, 20-year and 30-year cause specific survival were 99.3%, 99.3% and 96.5% respectively. The 10-year, 20-year and 30-year disease free survival were 83.6%, 70.7% and 64.0% respectively.

Thirty one patients had distant metastasis, all of which were lung metastases. Radioactive iodine was administered to twenty nine of these patients with a 69% response rate.

Conclusions: Prognosis of PTC in paediatric and adolescent populations is fair but recurrence of disease was often observed. Conservative therapy may be adequate in patients without any risk factors, but total thyroidectomy with neck dissection is advised for more aggressive cases


Thyroid Remnant Ablation With Different Methods Of Patient Preparation

Sanja, Kusacic Juna, Martina Ciglar-Hlasc, Marija Despot, Gordana Horvatic Herceg, Tatjana Samardzic, Drazen Huic,

Aim: To compare the rate of ablation with two modalities of patient preparation with the same dose of radioactive iodine (1850 MBq, 50 mCi)

Successful ablation of residue thyroid tissue after total thyroidectomy due to thyroid carcinoma requires an elevated TSH prior to ablative treatment.

This study included 77 patients (median age 49, range 16-78 years) with papillary carcinoma without any signs of metastatic disease at time of ablative treatment.

They were divided into two groups. The first group (n=42) who received ablation doses in the hypothyroid state. The second group (n=35) were placed on thyroid replace post-surgery and were subsequently treated in a euthyroid state after preparation with recombinant thyrotropin (rhTSH).

99% of patients had accumulation of activity in the thyroid bed on the post-ablative thyroid scan. There was no significant difference between rates of ablation between these two groups.

Conclusions: Comparable remnant ablation rates were seen in patients prepared by either the administration of rhTSH or withholding thyroid replacement. In both circumstances, 18050 MBq (50 mCi) dose was sufficient for a satisfactory thyroid ablation rate.


Laryngeal Preservation By Vertical Hemilarygopharyngectomy (VHLP) In Locally Advanced Thyroid Cancer

Min Sik Kim, Young-Hoon Joo, Kwang Jae Cho, Sang Yun Kim, Byung Jun Chun

Aim: To apply the VHLP technique in cases involving locally advanced thyroid cancer with laryngeal invasion and to evaluate the post-operative results.

Three patients were involved in this study with the diagnoses of spindle cell carcinoma, papillary carcinoma and anaplastic carcinoma of thyroid with paraglottic space invasion respective. In the latter case, there was recurrence of disease and the patient died two months after surgery. In the other two cases, there was no evidence of post-recurrent disease.

Conclusions: VHLP technique can be used to preserve laryngeal function in cases where there is locally advanced neck and neck cancer, especially in cases where there is invasion into the larynx.   


Goiter And Nodules

Serum TSH Levels And Malignancy Risk In Patients With Thyroid Nodules

Mira Siderova, Kiril Hristozov, Ivan Krasnaliev, Maria Petrova, Yana Bocheva 

Aim: To determine whether higher levels of TSH are associated with an increased incidence of thyroid malignancy in patients with nodular thyroid disease using cytological and histology results.

1483 patients (1339F/144M) with nodular thyroid disease were evaluated using fine needle aspiration biopsy (FNAB). The overall sensitivity and specificity of FNAB in predicting malignancy were 90.32% and 81.11% respectively. The reference range of TSH levels in malignant cytologies were significantly higher in comparison to benign cases (P<0.0001). Patients with factors influencing TSH concentration (ie. Hashimoto’s thyroiditis, thyroid replacement) were eliminated to preserve results.    

Conclusions: Cytological and histology results both suggest a direct relationship between high serum TSH and a risk of malignancy in thyroid nodules.


Surgery In Intrathoracic Goiter

Yvana Anavy Martinez Mateo, Francisco Juan de Santos Iglesias, Jose Manuel Gonzalez, Guillermo Jesus Vaquero Gajate, Leyre Rodrigo Hernanz

A 77-year old woman presented with dyspnea and dysphagia for solids. She was diagnosed with an intrathoracic goitre. The ultrasound showed an enlarged thyroid gland with multiple nodules. Surgical intervention was advised and proceeded with no complications.

Conclusions: 95% of intrathoracic goiters can be excised by cervical incision except in cases of advanced thyroid cancer, if the thyroid is too close to the vocal cords or if they are located in the posterior mediastinum. 


Intrathyroid Location Of Parathyroid Gland: A Significant Cause Of Inadvertent Parathyroidectomy During Thyroid Surgery?

Nick Michalopoulos, Efterpi Margaritidou, Theodossis Papavramidis, Ioannis Kanellos, Kalliopi Pazaitou-Panayiotou

Aim: To investigate the incidence of intrathyroid parathyroid glands (ITPGs) after having a total thyroidectomy and to determine whether there is a correlation with postoperative hypocalcaemia.

This was a retrospective study on 4500 patients who were divided into two groups: those with intrathyroid parathyroid gland (ITPG) and those with extrathyroid parathyroid gland (ETPG).

ITPGs presented in 68 cases (1.75%). Pathological characteristics between ITPGs and ETPGs were similar with respect to the size, localization and weight .

Conclusions: In this study, the presence of ITPGs does not increase the risk of clinical hypocalcaemia.


Small Nodular Lesions Of The Thyroid Gland In Children: Consider An Ectopic Thymus

Natallia Akulevich, Yulia Makarava, Julia Boiko, Irina Khmara

Aim: To analyze the evolution of an ectopic intrathyroid thymus in children.

The study was contacted on 26 children (14F/12M) aged 7.2±3.5 years.The time of follow-up was 1.6±0.6 years. Ectopic thymic tissue typically has characteristics of either single or multiple hypoechoic foci with hyperechoic inclusions, avascular, regular or irregular in shape and from 2-9 mm in maximal size. The majority of children presented with no goiter. The mean TSH level was 3.21.5 mIU/L.

At the end of the study, 24 patients had no growth of thyroid lesions and in 3 of these 24 patients, a decrease in size was observed. Surgergy was not performed on any of the patients.

Conclusions: An exctopic intrathyroid thymus should be considered in young children. Follow-up is mandatory but surgical intervention is not always necessary.


Evaluation Of The Incidence Of Thyroid Disorders In Patients With Systemic Lupus Erythematosus

Andrea Di Domenicantonio, Silvia Martina Ferrari, Poupak Fallahi, Ilaria Ruffilli, Marta Mosca, Alessandro Antonelli

Aim: To examine the incidence of clinical and subclinical thyroid dysfunction in women with systemic lupus erythematosus (SLE).

Conclusions: This study shows a high incidence of news cases of hypothyroidism, thyroid disorders, thyroid peroxidase antibodies (AbTPO) and the appearance of a hypoechoic thyroid in females with SLE in comparison with those in the control group.


Case Reports

Case Report: Superior Vena Cava Syndrome Secondary To Intrathoracic Goiter

Bruno Francisco Garcia-Bray, Nieves Cruz Felipe-Perez, Ricardo Darias-Garzon, Benigno Rivero-Melian, Jose Gregorio Oliva-Garcia, Estefania Gonzalez-Melo, Alejandra Mora-Mendoza, Beatriz Gomez-Alvarez, Ignacio Llorente-Gomez de Segura 

A 67 year-old woman presented with respiratory distress, cough and weight loss. Post examination and chest x-ray showed a mass occupying the upper and middle right lung lobes. A neoplasm is suspected and palliative radiotherapy is initially suggested. Chest and abdominal CT are done and an intrathoracic goiter is diagnosed and surgical intervention is indicated.

Conclusions: When a superior vena cava diagnosis is made, further tests should be performed to find the etiology of the disease. In this instance, the origin was a giant intrathoracic goiter. Thyroid function tests, and imaging techniques such as ultrasound or CT are advised to confirm before surgical intervention. 


Sunitinib-Induced Transient Thyrotoxicosis In A Patient With Renal Cell Carcinoma

Raluca Trifanescu, Oana-Gabriela Trifanescu, Mara Carsote, Catalina Poiana

A 39 year-old woman was treated with sunitinib for renal cell carcinoma. Thyroid function tests and antithyroid antibodies were normal during the first 6 months of treatment but after this period, the patient developed tachycardia, tremor in the extremities, anxiety and arterial hypertension. A diagnosis of thyrotoxicosis was made and a short-term glucocorticoid therapy was administered before resuming sunitinib treatment. One month later, the patient developed subclinical hypothyroidism followed by thyrotoxicosis again.

Conclusions: Close monitoring of thyroid function is recommended for patients undergoing treatment with sunitinib as recurrent episodes of thyrotoxicosis and hypothyroidism may occur.


Thyroid Cancer In Patients With Hyperthyroidism 

Martin Taylor, Anthony Skene, Joan McCutcheon

Aim: To review evidence whether patients with hyperthyroidism are at an increased risk of thyroid cancer.

A 44-year old woman presented with a toxic nodule.  She decided to have surgery due to child care concerns and was found to have a 8 mm papillary carcinoma adjacent to the nodule with a separate 2 mm focus of papillary carcinoma in lymph node tissue.

A 58-year old woman with a history of Graves disease and severe thyroid eye disease opted for a near-total thyroidectomy due to concerns over the use of radioactive iodine in the presence of thyroid eye disease. This patient was found to have a 9.5 mm minimally-invasive follicular carcinoma of the thyroid.

A 63-year old woman presented with a large goiter with a hot nodule. She had a thyroidectomy and was found to have an incidental 0.9 mm papillary carcinoma of the thyroid. She was subsequently treated with an ablative dose of radioactive iodine. 

Conclusions: It is now recognized that it is now quite common for patients with toxic multinodular goiters to have papillary thyroid cancer. 


Imaging And Nuclear Medicine

Predictive Factors Of Radioactive Iodine Therapy Failure In Graves’ Disease

Joana Nunes, Elisabete Rodrigues, Ana Oliveira, Tiago Vieira, Victor Alves, Berta Perez, Ricardo Correia, Davide Carvalho, Jorge Pereira

Aim: To determine some of the factors that may cause interference with the success rate of radioactive iodine therapy (RAI) in the treatment for Graves’ disease. 

Conclusions: Higher thyrotropin receptor antibodies, lower radioiodine doses and higher 131I uptake were shown to be associated with RAI failure.


Thyroid Cancer Pathogenesis

Warthin-Like Variant Of Papillary Thyroid Carcinoma: A Comparison With Classic Type In The Patients With Coexisting Hashimoto’s Thyroiditis

Chan Kwon Jung, Min-kyung Yeo, Ja Seong Bae, Sohee Lee, Min Hee Kim, Dong Jun Lim

Aim: To investigate the demographic and clinical characteristics of patients of Warthin-like variant of papillary thyroid (WLPTC) and those with classic cases of papillary thyroid carcinoma (PTC).

WLPTC is a rare subtype of PTC that resembles a Warthin tumor of the salivary glands.

40 patients were treated for WLPTC compared to the 200 who were treated for classic PTC at Seoul St Mary Hospital from 2012 to 2013. WLPTCs were more commonly associated with Hashimoto’s thyroiditis than those with PTC (93% vs. 36%, P<0.001). WLPTCs showed significantly lower rate of BRAF mutation when compared to classic PTCs (65% vs. 84%, P=0.007).

Conclusions: When comparing patients with WLPTC and PTC with coexisting Hashimoto’s thyroiditis, no significant differences in clinicopathologic characteristics and BRAF mutation rates between the 2 groups were noted.


Second Primary Malignancy In Patients With Thyroid Cancer

Stylianos Mandanas, Paschalia Iliadou, Pavlos Papakotoulas, Evanthia Giannoula, Vasiliki Chatzipavlidou, Kalliopi Pazaitou-Panayiotou

Aim: To evaluate associations of a second primary malignancy in patients with thyroid carcinoma (TC).

This was a retrospective study with patients from either TC or those from any other primary malignancy. They were divided into 3 groups. Group A (53 patients, 42%) were those who initially presented with TC, group B (60 patients, 48%) were those who had another type of cancer before TC and group C were those who were treated for both thyroid and another primary cancer simultaneously.

Conclusions: This study exhibited approximately the same proportion of second primary malignancies in patients from groups A and B. This indicates that the second primary malignancy is independent from the treatment given to TC. 


Thyroid In Reproduction And Development

Thyroid Volume And Calcitonin Levels During Pregnancy

Michela Perrino, Danila Covelli, Beatrice Vigo, Laura Fugazzola, Guia Vannucchi

Aim: To determine whether there is an increase in thyroid volume (TV) and calcitonin (CT) during pregnancy.

151 women (mean age 32.3 years, range 21.2-45.9) were enrolled in the study before their 12th week of pregnancy so their TV and CT levels could be monitored throughout the rest of their pregnancy.

Mean TV was noted at 8.9±2.5 mL at baseline reading and 8.8±2.6 mL and 9.4±2.7 mL in the second and third trimester respectively (P = 0.15). Those that presented initially with nodular goiters, no variations in the volume/number of nodules were observed.

Serum CT levels were 2.1±0.8 ng/dL at baseline reading and remained constant throughout second and third trimester (P=0.14).

Conclusions: This study demonstrated that TV and CT remain stable throughout pregnancy for women with sufficient iodine intake.    


Paediatrics And Pregnancy

TSH 2.5-3.4 Mu/L In The First Trimester Of Pregnancy

Antonia Perez-Lazaro, Alia Maria Garcia Castells, Sol Navas de Solis, Maria Isabel de Olmo Garcia, Susana Tenes Rodrigo, Rosa Camara Gomez, Juan Francisco Merino Torres

Aim: To monitor the progress of pregnant women with serum TSH levels between 2.5-4.9 mU/L in the first trimester and to consider treatment when their levels fall below 3.4 mU/L.

The American Thyroid Association (ATA) has led to the establishment of a new reference range for TSH (0.2-3.4 mU/L) in pregnant patients.

127 pregnant patients with elevated TSH were recruited to this study. Those that had a TSH above 3.4 mU/L were treated with Eutirox 38 mcg/day.

Conclusions: Since the introduction of new guidelines from the ATA, the number of patients classed with hypothyroidism has increased considerably. More studies are required to determine whether there are contraindications to the fetus when no treatment is given in pregnancy to those with a TSH between 2.5-3.4 mU/L.


Biochemical And Metabolic Parameters

Normal Ranges For Thyroid Hormones Age-Adjusted

Piedad Santiago, Pablo Olmedo, Carmen Gutierrez, Cristina Castillo, Maria Jose Martinez, Manuel Gasso

Aim:  To determine the normal ranges for thyroid hormones (after age adjustment) and to define the prevalence of autoimmune thyroid disease (ATD) in healthy populations.

584 women and 427 men were included in the study, which spanned over an age range of 1-65+.

Conclusions: The range of serum thyroid homrones in the healthy population is similar to the reference levels established in the laboratory. This population has exhibited lower ATD prevalence levels compared with previous studies and is higher in women compared to men.TSH was significantly higher in women compared to men (2.25μUI/mL compared to 1.97 25μUI/mL) and subjects were positive antithyroid antibodies have higher TSH levels.


Thyroid Gland Function Is Altered In Parkinson’s Disease

Emilio Fernandez, Angel Martin de Pablos, Jose Chacon, Jose-Manuel Garcia-Moreno

Aim: To determine whether the thyroid gland is related to idiopathic Parkinson’s disease.

Dysfunctions of the thyroid gland hand have been shown to be related to idiopathic Parkinson’s disease.

Conclusions: Elevated levels of thyroperoxidase in early-disease patients and low levels of serum 3-nitrotyrosine support a correlation between this disease and the thyroid gland.


Thyroid Function In Hospitalized Very Elderly: Association With Cognitive Function, Disability And Rehospitalisation

Cesar Esteves, Filipa Gomes, Francisco Cunha, Luis Silva, Vera Fontes, Marta Moura, Joao Vilcac, Vania Araujo, Paulo Bettencourt

Aim: To determine relationships between thyroid function and rates of morbidity and mortality.

Patients were 85+ and had been admitted to an internal medicine ward between 1st March and 31st December 2010.

191 patients (63M/128F) were included in the study. The mean age was 89±3.5 years. 93 patients (48.7%) exhibited normal thyroid function, 3 (1.6%) had hyperthyroidism, 11 (5.7%) had hypothyroidism, 68 (35.6%) were suggestive of euthyroid sick syndrome and the remainder did not fall into any of the groups. 

Significant correlations were found between free T3 and Modified Barthel index (MBI) and between T3/T4 ratio, Mini Mental State index (MMSI) and MBI. There was also a signification correlation between the number of rehospitalisations during follow-up and TSH.

Conclusions: T3 and T3/T4 ratio are correlated with MMIS and MBI. This suggests a relationship between thyroid function and disability in the elderly population.