Haruki Akasu

Video-assisted neck surgery: endoscopic resection of thyroid tumors with a very minimal neck wound

In recent years, endoscopic surgery has been widely applied with a view to minimizing tissue trauma and wound-related complications and improving cosmetic outcomes. Reports on its use in thyroid surgery are extremely scarce particularly with regard to exploiting the advantage of eliminating unattractive scars that we sometimes encounter in conventional operations on the exposed anterior part of the neck. We initially experimented and practiced endoscopic neck surgery on animals until we gained enough confidence for clinical application. After obtaining informed consent from patients and their families we began performing this new technique on patients with thyroid nodules; we termed this technique Video-Assisted Neck Surgery (VANS). We hereby report our early experience of VANS in the endoscopic resection of thyroid tumors in five patients, mainly looking at technical feasibility and the ability to reduce neck wounds to a minimum.

Endoscopic neck surgery with lymph node dissection for papillary carcinoma of the thyroid using a totally gasless anterior neck skin lifting method

Conventional open neck surgery requires a cervical collar incision on the anterior neck and leaves a scar in what is deemed to be a cosmetically undesirable location. In recent years, endoscopic neck surgery has been developed, first for parathyroidectomy by Gagner in 1996 and for thyroidectomy by Huscher and colleagues in 1997. These techniques reduce postoperative pain and the length of the hospital stay, and they provide an excellent cosmetic result. We developed a totally gasless endoscopic surgical treatment for thyroid and parathyroid tumors in 1998, and we have subsequently applied it to over 170 patients. We call this procedure the video-assisted neck surgery (VANS) method. Among these patients, almost all were given a diagnosis of benign thyroid nodule by fine-needle aspiration biopsy and underwent hemithyroidectomy without lymph node dissection. In eight patients, total hemithyroidectomy or subtotal thyroidectomy and lymph node dissection were performed for papillary carcinoma of the thyroid. The purpose of this study was to determine whether this surgical approach is feasible and safe for papillary carcinoma. In this article we report our experience applying endoscopic neck surgery to papillary carcinoma of the thyroid using a totally gasless anterior neck skin lifting method.

Video-assisted endoscopic thyroid and parathyroid surgery using a gasless method of anterior neck skin lifting: a review of 130 cases.

Abstract.Purpose: Endoscopic endocrine neck surgery is desirable from a cosmetic viewpoint. We compared the effectiveness of our new technique with that of conventional surgery in a clinical study. Methods: We performed our original endoscopic method of video-assisted neck surgery (VANS) on 130 patients: 126 with thyroid tumors and 4 with parathyroid tumors. The percentage of patients who underwent VANS among all those who underwent neck surgery and the procedure involved were analyzed. Operating time and blood loss were compared between the first 40 patients and last 39, and all factors were statistically analyzed in the most recent 20 patients who underwent the VANS method and the most recent 20 who underwent conventional surgery. Results: More than 60% of benign thyroid tumors and 5.3% of malignant thyroid tumors were operated on by the VANS method. Nearly total lobectomy was the most common procedure (57.7%), followed by total lobectomy (26.1%), for benign tumors. Malignancy was defined as papillary carcinoma less than 1 cm in diameter. Total lobectomy with lymph node clearance was performed for all malignant tumors. There was less bleeding when the VANS method (P < 0.001) was used than when conventional surgery was performed, and the operating time has been reduced with experience. Conclusion: The VANS method is feasible, practical, and safe, and has great cosmetic benefits.

Clinicopathologic Characteristics and Prognosis of Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma in Japan: An 18-Year Experience at a Single Institution

BackgroundDiffuse sclerosing variant (DSV) is a variant of papillary thyroid carcinoma that has diffuse involvement in one or both thyroid lobes without forming a dominant mass. We investigated the biological characteristics of DSV in Japan.MethodsWe investigated biological behaviors and prognoses of DSV in 35 patients who underwent surgical treatment between 1989 and 2007.ResultsAfter excluding papillary microcarcinoma, DSV accounts for 0.7% of papillary carcinoma. DSV occurs more frequently in younger patients and is clinically apparent as lymph node metastasis and lung metastasis more frequently than other papillary carcinomas, but the incidence of extrathyroid extension did not differ between the metastases. Routine radioiodine ablation therapy after initial surgery was not performed unless distant metastasis was clinically apparent at surgery. The disease-free survival rate of DSV was significantly worse than that of a pair-matched control group. However, only two patients, one with lung metastasis at surgery and another who underwent only palliative surgery, have died of carcinoma to date.ConclusionsAlthough cause-specific survival of DSV was good, its disease-free survival was worse than that of the control group because of the unavailability of routine radioiodine ablation therapy. Therefore, DSV requires careful surgical resection to minimize the carcinoma recurrence.

The miR-221/222 cluster, miR-10b and miR-92a are highly upregulated in metastatic minimally invasive follicular thyroid carcinoma

Minimally invasive follicular thyroid carcinoma (MI-FTC) is characterized by limited capsular and/or vascular invasion with good long-term outcomes. However, some cases of MI-FTC show a poor prognosis because of severe distant metastasis (i.e., metastatic MI-FTC). Nonetheless, no method has been established for predicting the prognosis of MI-FTC. This study was conducted to identify novel prognostic factors for metastatic MI-FTC by the use of microRNA (miRNA). Thirty-four patients with MI-FTC were categorized into two groups: the metastatic group, M(+) (n=12) and the non-metastatic group, M(−) (n=22). In the M(+) group, distant metastasis was recognized after the initial operation established the diagnosis of MI-FTC. In the M(−) group, no distant metastasis was recognized postoperatively for ≥10 years. Using laser micro-dissection followed by quantitative real-time PCR and PCR arrays, we performed a comprehensive expression profiling of 667 miRNAs in formalin-fixed, paraffin-embedded samples from the initial MI-FTC operation. Furthermore, we assessed the potential use of miRNAs as novel biomarkers for the metastatic potential of MI-FTC by logistic regression analysis. Comprehensive quantitative analysis of miRNA expression in MI-FTC samples revealed that the miR-221/222 cluster (i.e., miR-221, miR-222 and miR-222*), miR-10b and miR-92a were significantly upregulated in the M(+) group compared with the M(−) group. Interestingly, the expression levels of these miRNAs were also shown to be upregulated in widely invasive FTC (WI-FTC; n=13) that has distant metastasis and worse prognosis, indicating a close similarity in the miRNA expression between metastatic MI-FTC and WI-FTC. Logistic regression analysis revealed that miR-10b made a significant contribution to prognosis (OR 19.759, 95% CI 1.433–272.355, p= 0.026). Our findings suggest that miR-10b is a potential prognostic factor for evaluating the metastatic potential of MI-FTC at an initial operation stage.

Adenolipoma of the Thyroid Gland: Report of a Case

We report a case of adenolipoma of the thyroid gland, which is very unusual because thyroid adenoma rarely contains mature adipose tissue. A 55-year-old Japanese woman presented with a 1-month history of a neck mass. A blinded fine-needle aspiration biopsy showed benign follicular cells with no adipose cells, and we performed a left hemithyroidectomy. The specimen measured 7.0 × 4.4 cm and weighed 59.9 g. The cut surface of the tumor revealed a solid yellowish mass, and hematoxylin–eosin staining showed that the solid tumor was well separated from the adjacent thyroid tissue by a thin fibrous capsule. The tumor was found to be follicular adenoma composed of epithelial cells arranged in monotonous microfollicular patterns, intermingled with mature adipose tissue. No adipose tissue was found outside the tumor, and there were no signs of amyloid deposits in the tumor or adjacent thyroid tissue. The pathological diagnosis was adenolipoma of the thyroid gland. We discuss the pathogenesis of this entity and review the previously documented cases.

Excellent Prognosis of Patients with Nonhereditary Medullary Thyroid Carcinoma with Ultrasonographic Findings of Follicular Tumor or Benign Nodule

BackgroundMedullary thyroid carcinoma (MTC) accounts for only 1.4% of all thyroid malignancies in Japan. Generally, MTC shows ultrasonographic findings typical of thyroid carcinoma. However, in our experience, some MTC may be diagnosed as a follicular tumor or a benign nodule on ultrasonography because ultrasonographic findings of malignancy are lacking. In this study we investigated differences in biological behavior between these two types of MTC.MethodsSeventy-seven patients with nonhereditary MTC who underwent surgery in our department between 1988 and 2007 were enrolled in this study. Of these patients, 54 were diagnosed as having thyroid carcinoma (malignant, or M-type) but the remaining 23 were diagnosed as having follicular tumor or benign nodule (benign, or B-type) on ultrasonography.ResultsClinically apparent lateral node metastasis, extrathyroid extension, and extranodal tumor extension were observed in 37%, 17%, and 11% of M-type patients, respectively, but none of the B-type patients showed any of these features. All B-type patients but only 59% of M-type patients were biochemically cured. Lymph node metastasis was pathologically confirmed in 38 and 65% of B-type and M-type patients, respectively. Eight patients showed recurrence and three have died of carcinoma to date; all of these patients were M-type patients.ConclusionsB-type MTC is highly indolent and shows an excellent prognosis. However, thyroidectomy and lymph node dissection for B-type MTC should be the same as for M-type MTC because 38% of B-type MTC showed pathologic node metastasis.

Proteomic Profiling of Thyroid Papillary Carcinoma

Papillary thyroid carcinoma (PTC) is the most common endocrine malignancy. We performed shotgun liquid chromatography (LC)/tandem mass spectrometry (MS/MS) analysis on pooled protein extracts from patients with PTC and compared the results with those from normal thyroid tissue validated by real-time (RT) PCR and immunohistochemistry (IHC). We detected 524 types of protein in PTC and 432 in normal thyroid gland. Among these proteins, 145 were specific to PTC and 53 were specific to normal thyroid gland. We have also identified two important new markers, nephronectin (NPNT) and malectin (MLEC). Reproducibility was confirmed with several known markers, but the one of two new candidate markers such as MLEC did not show large variations in expression levels. Furthermore, IHC confirmed the overexpression of both those markers in PTCs compared with normal surrounding tissues. Our protein data suggest that NPNT and MLEC could be a characteristic marker for PTC.

Histological study of papillary thyroid carcinoma treated with percutaneous ethanol injection therapy.

An 86‐year‐old male patient was treated by percutaneous ethanol injection therapy (PEIT), following tumorectomy of a papillary thyroid carcinoma and a modified radical neck dissection for its metastasis. After seven treatments with PEIT, the patient was admitted to hospital for a tracheotomy to treat progressive severe dyspnea. Seven days later the patient died from acute renal failure caused by diabetic ketoacidosis. At autopsy, tumor masses were found to comprise mostly scar tissue, and the remaining neoplastic cells often showed anaplastic changes. Fresh coagulation necrosis and hemorrhages were scattered throughout the tumor lesions and their microvessels were occasionally occluded by thrombus. These changes were seen prominently, especially at the central areas of PEIT treatment. Given these findings, we believe that PEIT may be useful in providing local control for the progression of thyroid cancer, especially in cases of unresectable malignant thyroid tumors.

Column 2. Prevalence of Various Histological Types of Thyroid Cancer

Among the thyroid cancers, papillary carcinoma is the most common, followed by follicular carcinoma, medullary carcinoma, anaplastic carcinoma, malignant lymphoma, and others.