Search

Context: Broad genomic analyses among thyroid histologies have been described from relatively small cohorts.Objective: Investigate the molecular findings across a large, real-world cohort of thyroid fine-needle aspiration (FNA) samples.Design: Retrospective analysis of RNA sequencing data files.Setting: Clinical Laboratory Improvement Amendments laboratory performing Afirma Genomic Sequencing Classifier (GSC) and Xpression Atlas (XA) testing.Participants: A total of 50 644 consecutive Bethesda III-VI nodules.Intervention: None.Main Outcome Measures: Molecular test results.Results: Of 48 952 Bethesda III/IV FNAs studied, 66% were benign by Afirma GSC. The prevalence of BRAF V600E was 2% among all Bethesda III/IV FNAs and 76% among Bethesda VI FNAs. Fusions involving NTRK, RET, BRAF, and ALK were most prevalent in Bethesda V (10%), and 130 different gene partners were identified. Among small consecutive Bethesda III/IV sample cohorts with one of these fusions and available surgical pathology excision data, the positive predictive value of an NTRK or RET fusion for carcinoma or noninvasive follicular thyroid neoplasm with papillary-like nuclear features was >95%, whereas for BRAF and ALK fusions it was 81% and 67%, respectively. At least 1 genomic alteration was identified by the expanded Afirma XA panel in 70% of medullary thyroid carcinoma classifier-positive FNAs, 44% of Bethesda III or IV Afirma GSC suspicious FNAs, 64% of Bethesda V FNAs, and 87% of Bethesda VI FNAs.Conclusions: This large study demonstrates that almost one-half of Bethesda III/IV Afirma GSC suspicious and most Bethesda V/VI nodules had at least 1 genomic variant or fusion identified, which may optimize personalized treatment decisions. [ABSTRACT FROM AUTHOR]

Objective: FDG-PET/CT (fluorodeoxyglucose-positron emission tomography/computed tomography) is effective to assess for occult neck nodal disease. We report risks and patterns of nodal disease based on primary site and nodal level from data on the dissected cN0 per the results from ACRIN 6685.Study Design: Prospective nonrandomized enrollment included participants with first-time head and neck squamous cell carcinoma and at least 1 cN0 neck side to be dissected.Setting: Twenty-four ACRIN-certified centers internationally (American College of Radiology Imaging Network).Methods: A total of 287 participants were enrolled. Preoperative FDG-PET/CT findings were centrally reviewed and compared with pathology. Incidence, relative risk, pattern of lymph node involvement, and impact upon neck dissection were reported.Results: An overall 983 nodal levels were dissected (n = 261 necks, n = 203 participants). The highest percentages of ipsilateral positive nodes by primary location and nodal level were oral cavity (level I, 17/110, 15.5%), pharynx (level II, 6/30, 20.0%), and larynx (level VI, 1/3, 33.3%).Conclusion: Levels at greatest risk for nodal disease in cN0 in terms of ipsilateral neck dissection are level I (oral cavity), II (pharynx), and VI (larynx). These data should be considered when treating patients presenting with cN0. This is the first study to comprehensively report the incidence, location, and risk of metastases in cN0 in the FDG-PET/CT era. [ABSTRACT FROM AUTHOR]

Objective: To quantify how frequently intraoperative parathyroid hormone levels increase during thyroid surgery and to explore a possible relationship between secondary hyperparathyroidism due to vitamin D deficiency and elevation in intraoperative parathyroid hormone.Study Design: Case series with chart review.Setting: Tertiary academic center.Subjects and Methods: A total of 428 consecutive patients undergoing completion and total thyroidectomy by the senior author over a 7-year period were included for analysis. All patients had baseline and postexcision intraoperative parathyroid hormone levels as well as vitamin D levels from the same laboratory. Institute of Medicine criteria were employed for vitamin D stratification (>30, normal; 20-29.9, insufficient; <20, deficient) . Other data analyzed include sex, age, neck dissection status, and parathyroid autotransplantation.Results: A total of 118 patients (27.6%) had an intraoperative parathyroid hormone elevation above baseline. Patients with vitamin D deficiency were significantly more likely to experience hormone elevation ( P = .04). When parathyroid hormone rose, it did so by a mean 32.1 pg/mL. Patients with vitamin D deficiency demonstrated significantly larger hormone increases ( P = .03).Conclusion: Elevation in intraoperative parathyroid hormone levels above baseline after completion and total thyroidectomy occurs in over one-fourth of cases and is significantly associated with vitamin D deficiency. This study is the first to report this observation. We hypothesize that vitamin D deficiency in these patients may create a subclinical secondary hyperparathyroidism that leads to intraoperative parathyroid hormone elevation when the glands are manipulated. Additional studies will be needed to explore this physiologic mechanism and its clinical significance. [ABSTRACT FROM AUTHOR]

Background Robotic surgery has been recently used as a novel tool for remote access thyroid surgery. We performed a meta-analysis of the current literature to examine the safety and oncological efficacy of robotic surgery compared to endoscopic and conventional approaches for different thyroid procedures. Methods A systematic search of the online data bases was done using the following (MeSH) terms "robotic surgery," "robotic thyroidectomy," "robot-assisted thyroidectomy," and "robot-assisted thyroid surgery." Outcomes measured included total operative time, length of hospital stay, postoperative thyroglobulin levels, and postoperative complications. Statistical differences were analyzed between groups through the standard means and/or relative risk by using STATA analytical software. Results In this study, 144 articles were identified; of which 18 of them met our inclusion criteria, totaling 4878 patients. Robotic approach was associated with longer total operative time (mean difference of 43.5 minutes) when compared to the conventional cervical approach (95% CI = 20.9-66.2; P < .001). Robotic approach was also found to have a similar risk of total postoperative complications when compared to the conventional and endoscopic approaches. Conclusion Robotic thyroid surgery is as safe, feasible and provides similar periperative complications and oncological outcomes when compared to both, conventional cervical and endoscopic approaches. However, robotic thyroid surgery is associated with longer operative time when compared to the conventional open approach. [ABSTRACT FROM AUTHOR]

Objective: To describe a safe and effective postoperative prophylactic calcium regimen for same-day discharge thyroid and parathyroid surgery.Study Design: Case series with chart review.Setting: Tertiary referral academic institution.Subjects and Methods: In total, 162 adult patients who underwent total thyroidectomy, completion thyroidectomy, unilateral parathyroidectomy, parathyroidectomy with bilateral neck exploration, or revision parathyroidectomy were identified preoperatively to be candidates for same-day discharge. All patients in this study were successfully discharged the same day on our standard prophylactic calcium regimen.Results: Less than 1% (1/162) of patients re-presented to the hospital within 30 days of surgery, and that patient was successfully discharged from the emergency department after negative workup for hypocalcemia. There was no significant difference between preoperative and postoperative calcium levels in the total/completion thyroidectomy groups (9.3 vs 9.2 mg/dL, respectively; P = .14). The average postoperative calcium level in the parathyroid group was well within normal limits (9.5 mg/dL), and the difference in postoperative calcium levels between revision and primary parathyroidectomy cases was not significantly different (P = .34).Conclusion: The reported calcium regimen demonstrates a safe, effective, and objective means of postoperative calcium management in outpatient thyroid and parathyroid surgery in appropriately selected patients. [ABSTRACT FROM AUTHOR]

Introduction: A long-term goal of our group is to develop proteomic-based approaches to the detection and use of protein biomarkers for improvement in diagnosis, prognosis, and tailoring of treatment for head and neck squamous cell cancer (HNSCC). We have previously demonstrated that protein expression profiling of serum can identify multiple protein biomarker events that can serve as molecular fingerprints for the assessment of HNSCC disease state and prognosis.Methods: An automated Bruker Daltonics (Billerica, MA) ClinProt matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometer was used. Magnetic chemical affinity beads were used to differentially capture serum proteins prior to MALDI-TOF analysis. The resulting spectra were analyzed using postprocessing software and a pattern recognition genetic algorithm (ClinProt 2.0). An HNSCC cohort of 48 sera samples from 24 patients consisting of matched pretreatment and 6 to 12 month posttreatment samples was used for further analysis. Low-mass differentially expressed peptides were identified using MALDI-TOF/TOF.Results: In the working mass range of 1,000 to 10,000 m/z, approximately 200 peaks were resolved for ionic bead capture approaches. For spectra generated from weak cation bead capture, a k-nearest neighbor genetic algorithm was able to correctly classify 94% normal from pretreatment HNSCC samples, 80% of pretreatment from posttreatment samples, and 87% of normal from posttreatment samples. These peptides were then analyzed by MALDI-TOF/TOF mass spectometry for sequence identification directly from serum processed with the same magnetic bead chemistry or alternatively after gel electrophoresis separation of the captured proteins. We were able to compare this with similar studies using surface-enhanced laser desorption ionization (SELDI)-TOF to show this method as a valid tool for this process with some improvement in the identification of our groups.Conclusions: This initial study using new high-resolution MALDI-TOF mass spectrometry coupled with bead fractionation is suitable for automated protein profiling and has the capability to simultaneously identify potential biomarker proteins for HNSCC. In addition, we were able to show improvement with the MALDI-TOF in identifying groups with HNSCC when compared with our prior data using SELDI-TOF. Using this MALDI-TOF technology as a discovery platform, we anticipate generating biomarker panels for use in more accurate prediction of prognosis and treatment efficacies for HNSCC. [ABSTRACT FROM AUTHOR]

Objective: Fluorodeoxyglucose (FDG) whole body positron emission tomography (PET) scan may show clinically occult second lesions. Such lesions in the thyroid are increasingly common. There are several recent reports of a high probability of malignancy in these lesions ranging from 14% to 63%. Study Design and Setting: This is a retrospective review of 15,711 PET scans at a multi-disciplinary thyroid clinic at a tertiary care university medical center. Twenty-two patients were referred with thyroid PET "incidentalomas." The review included 18 FDG-PET scans, ultrasound guided fine needle aspiration biopsies, and thyroid surgery pathology. Aspiration cytology or pathology were the main outcome measures. Results: Three patients had malignancy of the PET-positive thyroid lesions. Papillary thyroid micro carcinomas were detected in four of the specimens that showed a benign pathology of the dominant nodule. Conclusion: Our experience shows a 14% malignancy rate for the dominant (imaged) nodule and a total malignancy rate of 32% when the incidental micro carcinomas are included. Both of these rates are significantly lower than results published previously. [ABSTRACT FROM AUTHOR]

Objective: Amiodarone can cause thyroid dysfunction in patients with or without previous thyroid disease. With increased use from its placement in advanced cardiac life support guidelines and cardiac transplant programs, the incidence of amiodarone-induced thyrotoxicosis (AIT) will likely increase. Medical management is complex and nonuniform and frequently fails. This study investigates the role of surgery in AIT and proposes indications for surgical management.Study Design and Setting: Two AIT case reports at a tertiary care institution and 31 surgical AIT cases in the world literature are reviewed.Methods: The 2 AIT cases involved patients with cardiomyopathy and resistant arrhythmias. Despite medical therapy, both patients' conditions failed to improve. Thirty-one surgical cases of AIT in the literature are evaluated with respect to symptoms and onset, medical therapy, AIT classification, pathology, perioperative management, and complications.Results: Both patients underwent total thyroidectomy without difficulty or complication, one as an overnight stay and one as an inpatient with an intraaortic balloon pump. One patient received a successful cardiac transplant and the other remains a viable candidate. In the literature, the majority (80%) of surgical cases are AIT type II (less common type) with no underlying thyroid disease. Range and duration of symptoms varied, in addition to type and duration of medical management. Almost all patients underwent total thyroidectomy, and all were successful with no mortality and minimal morbidity.Conclusion: AIT can develop in any patient during or after amiodarone therapy. Medical management is extremely difficult due to the absence of a proven therapeutic armamentarium, and surgery offers a safe, viable option. Surgical management should play a larger role in treatment algorithms and should be strongly considered for patients whose conditions necessitate continuation of amiodarone, or with severe symptoms resistant to medical therapy. [ABSTRACT FROM AUTHOR]

Radio-guided surgery is an established means for surgeons to identify a target of interest for biopsy or excision. This technique is used for a variety of malignancies as well as minimally invasive parathyroid surgery. The primary radionuclide used for these procedures is technetium-99m (Tc-99m), but others have been used. Use of (18)fluorine-fluorodeoxyglucose ((18)F-FDG) in oncology has proliferated. This has created the opportunity to use (18)F-FDG as a potential radio tracer in the operating room. A pilot study of three patients with non-iodine avid thyroid cancers undergoing (18)F-FDG-guided revision thyroid cancer surgery is reported. Radiation exposure to operating room personnel was measured. Radiation exposure to the surgeon and staff members of an operating room is well below the limits of the National Regulatory Commission. Therefore, utilization of this radiopharmaceutical intraoperatively should not be limited in the future because of concern regarding exposure of operating room personnel to radiation. [ABSTRACT FROM AUTHOR]