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Non-recurrent inferior laryngeal nerve (NRILN) is rare but one of the important anatomical variations in thyroid and parathyroid surgery. Almost all cases were observed on the right side with aberrant right subclavian artery and left NRILN have been reported in only five cases so far. Here, we reported a 38 year-old Japanese male with left NRILN accompanying adenomatous goiter. He was referred to our hospital for the surgical treatment of left thyroid goiter. Preoperative computed tomography revealed right-sided aortic arch and aberrant left subclavian artery with no signs of complete situs inversus viscerum, suggesting possible left NRLN. Left hemithyroidectomy was performed using nerve monitoring system. Intraoperatively, left recurrent laryngeal nerve was not identified along tracheoesophageal groove, but directly originated from vagal nerve and was running horizontally to larynx. Mobility of vocal cords were not impaired and postoperative course was uneventful. During thyroid surgery for the patients with right-sided aortic arch, meticulous care should be taken using nerve monitoring system to avoid nerve injury., Competing Interests: Declaration of Competing Interest All authors have no conflict of interests to be disclosed on this work., (Copyright © 2020. Published by Elsevier B.V.)

To clarify the patterns of the recurrence and to assess the oncological and functional outcomes after salvage surgery for the patients with structural local recurrence of papillary thyroid cancer (PTC), twenty-five patients who underwent salvage surgery for structural local recurrence of PTC were retrospectively reviewed. Structural recurrences were observed in the tracheal lumen in 5 patients, intraluminal or intramuscular esophagus in 5 patients, trachea, and cricoid cartilage in 9 patients, cricoid and thyroid cartilage in 2 patients, intra-lumen of the larynx in 1 patient and soft tissue around thyroid in 3 patients, respectively. Although all local disease was resected with macroscopically negative margin, 10 patients diagnosed as microscopically positive margin. Major surgical complications occurred in 6 patients, including common carotid artery injury (n = 1), unintentional pharyngeal or esophageal injury (n = 2), recurrent laryngeal nerve paralysis (n = 2), and pharyngeal fistula resulting in common carotid artery rupture (n = 1), and were successfully managed. During the follow-up periods, 6 patients were alive without disease, 15 patients survived with distant metastases and/or locoregional recurrence, and 4 patients died of the disease. While tracheocutaneous fistula remained in 7 patients, the vocal function was preserved in all patients but one who underwent total laryngectomy. Normal oral intake was retained in all patients. In conclusion, although salvage surgery for structural recurrence of PTC has a high risk of complications, it may be worthwhile when macroscopic curative resection is available. The decision should be made considering various factors including curability, risk of surgical procedure, functional outcome, and life expectancy.

Papillary thyroid carcinoma (PTC) occasionally invades tracheal cartilages. We adapted a reconstructive procedure "modified spiral tracheoplasty" to extensive tracheal defect after resection of locally advanced thyroid cancer. Extensive window resection of tracheal wall was performed in a 72-year-old woman and a 48-year-old man with PTC invading intraluminal trachea. Remaining stumps of trachea were separated from the esophageal wall and were rotated by 90 degrees in opposite directions. Posterior and lateral walls were anastomosed and tracheocutaneous fistula was created to prevent postoperative airway obstruction. Postoperative course was uneventful in both cases. Tracheocutaneous fistula was successfully closed 3 to 4 months after the initial surgery. Modified spiral tracheoplasty is a safe and useful method to recreate a framework of trachea after extensive window resection for advanced thyroid cancer., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Multitarget kinase inhibitors (m-TKI), including lenvatinib, are now available as treatment options for radioiodine-refractory differentiated thyroid cancer (RR-DTC). However, the optimal timing of treatment initiation with m-TKI in these patients remains to be defined., Methods: We retrospectively reviewed the clinical records of 30 consecutive patients with RR-DTC. The relationship between clinical characteristics was evaluated, including tumor growth parameters at pretreatment/post-treatment and efficacy of lenvatinib., Results: A total of 26 patients with RR-DTC treated with lenvatinib were evaluable for response and eligible for analysis. From the results of multivariate analysis, baseline tumor size and tumor-related symptoms were independent negative prognostic factors for overall survival (OS) and progression-free survival (PFS). Pretreatment tumor growth parameters were not prognostic for either PFS or OS., Conclusions: Patients with RR-DTC with a high tumor burden and tumor-related symptoms had significantly worse prognosis. Greater tumor reduction after starting lenvatinib may lead to better prognosis, irrespective of pretreatment high tumor growth rate., (© 2019 Wiley Periodicals, Inc.)

Background: Papillary thyroid carcinoma frequently metastasizes to central and lateral neck lymph nodes, but metastasis to retropharyngeal lymph nodes (RPLN) is rare., Patients and Methods: We retrospectively reviewed 16 patients with RPLN metastasis of PTC who underwent therapeutic dissection of RPLN metastases., Results: Among 16 patients, 7 patients underwent RPLN dissection with initial surgery and remaining 9 patients as salvage surgery. RPLN metastasis arose unilaterally in 15 patients and bilaterally in 1 patient. Eleven patients showed temporal dysphagia and four patients showed temporal vocal cord paralysis, but both symptoms eventually recovered in all cases. Two patients with salvage RPLN dissection died of distant metastasis and six patients survived with distant metastasis and/or persistent loco-regional disease. Other eight patients have been alive without disease., Conclusions: Although transcervical approach for RPLN metastases of PTC provided acceptable functional and oncological outcomes, half of the patients with RPLN metastasis have had distant metastasis and/or persistent locoregional disease. Indications of surgery for patients with RPLN metastasis need to be performed carefully in consideration of patients' prognosis and quality of life.

Sorafenib and lenvatinib showed efficacy for patients with radioactive iodine (RAI)-refractory differentiated thyroid cancer (DTC) in pivotal phase 3 clinical trials. Although the efficacy of lenvatinib in patients who received previous treatment with multi-target kinase inhibitors (m-TKIs), including sorafenib, was reported, the efficacy of sorafenib in patients who previously received lenvatinib remains unknown. A 75-year-old woman diagnosed as RAI-refractory poorly differentiated carcinoma with multiple lung metastases and started treatment with lenvatinib. She continued to receive lenvatinib but with repeated dose interruptions and reductions due to continuous proteinuria. Because of severe and persistent proteinuria as well as newly developed renal impairment, lenvatinib was suspended after two years of treatment. After the 7-month suspension, her proteinuria and renal impairment were partially improved, but her lung metastases progressed. Because she was unable to tolerate previous treatment with lenvatinib, sorafenib was started. At 7 months of treatment with sorafenib, her lung metastases shrank and she could continue sorafenib without exacerbation of proteinuria or renal impairment. This case may suggest that sorafenib does not exacerbate the proteinuria or renal impairment induced by lenvatinib, and may be an effective treatment option for RAI-refractory DTC patients who are unable to tolerate lenvatinib., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: Postoperative hypoparathyroidism (HPT) is one of the most common complications in total thyroidectomy for thyroid carcinoma. Parathyroid glands (PTGs) are at risk of being damaged during total thyroidectomy and central neck dissection mainly due to inadvertent removal, interruption of the blood supply or hematoma formation. The purpose of this study was to evaluate the efficacy of our surgical procedure to preserve for parathyroid function retrospectively and to clarify the risk factors of HPT after total thyroidectomy for thyroid cancer., Patients and Methods: Sixty-five patients undergoing total thyroidectomy with central neck dissection for thyroid cancer were enrolled in this retrospective study. Cancers were diagnosed as stage I in 15 patients, stage II in 24 patients, stage III in 19 patients, and stage IV in 7 patients. Lateral neck dissection and upper mediastinal dissection were simultaneously performed in 47 patients and one patient, respectively. Parathyroid glands (PTGs) were preserved in situ in 34 patients. Among 31 patients in whom PTG could not be preserved in situ, two or more PTGs were autotransplanted in 9 patients and one PTG was autotransplanted in 18 patients. PTG was not autotransplanted in 4 patients, since it could not be identified during the surgery., Results: Postoperative transient HPT and permanent HPT were observed in 44 (68%) patients and in 12 (18%) patients, respectively. Among 34 patients in whom PTGs were preserved in situ, transient HPT and permanent HPT were observed in 17 (50%) patients and in 6 (2%) patients, respectively. Among 31 patients in whom PTG were not preserved in situ, postoperative permanent HPT was observed in all 4 patients without PTG autotransplantation, and 6 (33%) out of the 18 patients who had one PTG autotransplantation. On the other hand, none of the 9 patients who had two or more PTG autotransplantation at the time of thyroidectomy developed permanent HPT (P=0.04). The patients with large tumor (≥40mm) and/or gross extra glandular invasion had a significantly higher risk of permanent postoperative HPT compared with the patients without these pathological features (P<0.01)., Conclusions: Two or more PTG should be autotransplanted in case where PTG is not preserved in situ to prevent postoperative HPT after total thyroidectomy with central neck dissection, especially in cases of large tumor and/or gross extrathyroidal extension., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Quality of voice after immediate recurrent laryngeal nerve (RLN) reconstruction in thyroid cancers has not been thoroughly studied., Methods: Thirteen patients with fixed vocal cords (fixed vocal cord group) and 8 patients with intact or impaired mobile vocal cords (mobile vocal cord group) who had immediate RLN reconstruction simultaneously with total thyroidectomy, and patients who had arytenoid adduction and thyroplasty for vocal cord paralysis caused by previous surgery (arytenoid adduction thyroplasty group) were enrolled in this study., Results: Preoperative phonation efficiency index was significantly lower (p = .008) in the fixed vocal cord group than in the mobile vocal cord group. One year after surgery, all voice parameters of the patients in the fixed vocal cord group had improved, compared with their preoperative data. The fixed vocal cord group had attained satisfactory voice qualities equivalent to those of the mobile vocal cord group in terms of various voice parameters., Conclusion: The present results support the idea that immediate RLN reconstruction at the time of surgery for thyroid cancers may spare the need for subsequent arytenoid adduction thyroplasty even in the patients with preoperatively fixed vocal cords. © 2016 Wiley Periodicals, Inc. Head Neck 39: 427-431, 2017., (© 2016 Wiley Periodicals, Inc.)