Jandee Lee

Quality of Life and Effectiveness Comparisons of Thyroxine Withdrawal, Triiodothyronine Withdrawal, and Recombinant Thyroid-Stimulating Hormone Administration for Low-Dose Radioiodine Remnant Ablation of Differentiated Thyroid Carcinoma

BACKGROUND Few reports have examined the use of recombinant human thyroid-stimulating hormone (rhTSH) for ablation of postsurgical thyroid remnants after low-dose radioactive iodine (RI) therapy, compared with conventional thyroid hormone withdrawal. We investigated whether patient preparation using rhTSH was comparable to conventional thyroid hormone withdrawal with respect to efficacy of postsurgical remnant ablation in low-risk patients receiving a 30 mCi RI. In addition, we also evaluated the impact of rhTSH (rhTSH vs. conventional thyroid hormone withdrawal) on quality of life (QoL) of thyroid cancer patients undergoing RI ablation. METHODS This study included three groups of patients, enrolled consecutively. From February 2006 to March 2007, 291 patients were enrolled and randomized, after total thyroidectomy: (1) withdrawal of levothyroxine (LT4) for 4 weeks (T4-WD Group, n = 89), (2) withdrawal of LT4 for 4 weeks plus 2 weeks on and then 2 weeks off liothyronine (LT3) (T3-WD Group, n = 133), and (3) rhTSH administration (rhTSH Group, n = 69). QoL was determined at the time of ablation. RESULTS Patients in the three groups did not differ significantly in baseline characteristics or tumor, node and metastasis (TNM) staging. In all study groups, serum TSH levels showed very good stimulation (mean, 82.24 +/- 18.21 mU/L), without significant between-group differences (p = 0.5213). Follow-up examinations were performed 12 months after ablation to assess ablation outcome in each group by 131 whole body scans (WBSs), serum thyroglobulin measurement after TSH stimulation, and neck ultrasonography. The successful ablation rate was 91.0% in T4-WD Group, 91.7% in T3-WD Group, and 91.3% in rhTSH Group, without significant between-preparation differences (p = 0.2061). QoL was better preserved in rhTSH Group than in T4-WD and T3-WD Groups (p < 0.0001). However, there was no QoL difference at the time of ablation between T4-WD and T3-WD Groups. CONCLUSIONS Our study indicates that use of rhTSH preserves QoL in patients undergoing RI ablation and affords an ablation success rate comparable to that seen after thyroid hormone withdrawal. Notably, ablation preparation using withdrawal of LT3 for 2 weeks did not prevent development of profound hypothyroidism, as also occurred when LT4 alone was withdrawn for 4 weeks.

Differentiated thyroid carcinoma presenting with distant metastasis at initial diagnosis clinical outcomes and prognostic factors.

Objectives:Distant metastasis (DM) is seldom observed at initial presentation of differentiated thyroid carcinoma (DTC), making it difficult to assess the clinical characteristics and treatment outcomes of DTC patients with DM. We therefore retrospectively assessed these parameters in DTC patients who presented with DM between July 1994 and December 2007. In addition, we compared biologic behaviors and prognostic factors between patients presenting with DM and those developing DM after initial treatment. Methods:Among 1560 DTC patients who underwent thyroidectomies during the 13.5-year study period, 91 patients were included in this study; 52 patients (3.4%) displayed DM at initial presentation and 39 (2.5%) developed DM after initial 131radiacitive iodine (RI) treatment. Metastatic lesions were treated with high dose RI (94.5%), surgical resection (14.3%), external beam radiation therapy (31.9%), embolization of feeding vessels (1.1%), and/or chemotherapy (1.1%). Median duration of follow-up was 75 months (range, 12–158 months). Results:Mean patient age was 57 years (range, 13–80 years), and the female-to-male ratio was 2.03:1. Metastases were detected in the lung only (68.1%), bone only (16.5%), and multiple sites (15.4%). When clinical and tumor characteristics were considered, metastatic lesion iodine avidity was significantly higher in patients presenting with DM. At 5 and 10 years, the overall survival (OS) rates in patients presenting with DM were 83.8% and 72.1%, respectively, and the disease-specific survival (DSS) rates were 68.5% and 26.8%. OS did not differ significantly between patients presenting with DM and those developing DM after initial treatment. However, those with initial DM enjoyed significantly improved DSS compared with patients who developed DM after initial treatment. At last follow-up, 22 patients (24.2%) were alive without disease, 48 (52.7%) were alive with disease, and 21 (23.1%) had died of disease in study patients. Multivariate Coxs regression analyses showed that complete local control was a significant predictor of OS and DSS in all study patients. In patients developing DM after initial treatment, metastatic lesion iodine avidity was also associated with both OS and DSS. In contrast, avidity was associated only with DSS in patients presenting with DM. Conclusions:Our study showed that DTC patients presenting with initial DM appear to have relatively favorable outcomes compared with DTC patients who developed DM after initial treatment. Complete local control may be the most important prognostic indicator in all DM patients. Metastatic lesion iodine avidity had a significant impact on both OS and DSS in patients developing DM after initial treatment, but significantly influenced only DSS in patients presenting with initial DM.

Comparative Analysis of Oncological Outcomes and Quality of Life After Robotic versus Conventional Open Thyroidectomy With Modified Radical Neck Dissection in Patients With Papillary Thyroid Carcinoma and Lateral Neck Node Metastases

OBJECTIVES Robotic total thyroidectomy (TT) with modified radical neck dissection (MRND) using a gasless transaxillary approach has been reported safe and effective in patients with N1b papillary thyroid carcinoma (PTC), with notable cosmetic benefits when compared with conventional open TT. We have compared oncological outcomes and quality of life (QoL) in PTC patients undergoing robotic TT and MRND and those undergoing conventional open procedures. MATERIALS AND METHODS Between March 2010 and July 2011, 128 patients with PTC and lateral neck node metastases underwent TT with MRND, including 62 who underwent robotic and 66 who underwent open TT. We compared oncologic outcomes and safety as well as functional outcomes such as postoperative subjective voice and swallowing difficulties. We also evaluated neck pain, sensory changes, and cosmetic satisfaction after surgery using various QoL symptom scales. Neck and shoulder disability was assessed using arm abduction tests (AAT) and questions from the neck dissection impairment index (NDII). RESULTS Although the mean operating time was significantly longer in the robotic (mean, 271.8 ± 50.2 min) than in the open group (mean, 208.9 ± 56.3 min) (P < .0001), postoperative complication rates and oncologic outcomes, including the results of radioactive iodine scans and postoperative serum Tg concentrations, did not differ significantly. Subjective voice outcomes and postoperative AAT and neck dissection impairment index were also similar, but postoperative swallowing difficulties (P = .0041) and sensory changes (P < .0001) were significantly more frequent in the open than in the robotic group. In particular, mean cosmetic satisfaction score was significantly higher in the robotic than in the open group (P < .0001). CONCLUSIONS Robotic TT with MRND yielded similar oncologic outcomes and safety as conventional open procedures, with similar recovery of neck and shoulder disability. However, the robot technique resulted in better QoL outcomes, including better cosmetic results and reductions in neck sensory changes and swallowing discomfort.

Long-Term Outcomes of Total Thyroidectomy Versus Thyroid Lobectomy for Papillary Thyroid Microcarcinoma: Comparative Analysis After Propensity Score Matching

AIMS The objectives of this study were to compare long-term outcomes after total thyroidectomy (TT) or thyroid lobectomy (LT) in a large cohort of patients with papillary thyroid microcarcinoma (PTMC), and to determine whether tumor size (≤0.5 cm vs. >0.5 cm) has a significant impact on the extent of surgery. METHODS We evaluated 2014 patients with PTMC who underwent TT with central compartment node dissection (CCND; n = 1015) or LT with CCND (n = 999) between March 1986 and December 2006 and for whom complete follow-up data were available for at least 5 years (median 11.8 years, range 5-26 years). Using propensity score matching to reduce the impact of treatment selection bias and potential confounding in an observational study, we compared overall survival and disease-free survival in the overall cohort and in patients with tumors ≤0.5 cm and >0.5 cm in size. RESULTS After adjustment for differences in baseline clinicopathologic risk factors, we observed no significant differences between the LT and the TT groups in the risk of death (hazard ratio for the LT group 1.05, 95% confidence interval [CI] 0.71-1.47, p = 0.890) and locoregional recurrence (hazard ratio for the LT group 3.08 [CI 1.99-8.05], p = 0.194) in the overall matched cohort. Similar results were observed when we compared LT and TT in patients with tumors ≤0.5 cm and >0.5 cm. CONCLUSIONS The long-term rates of death and locoregional recurrence were similar in patients with PTMC who underwent LT with CCND and those who underwent TT with CCND. Therefore, completion thyroidectomy may not be recommended unless recurrence after LT is definitely detected in low-risk PTMC patients, and close follow-up is adequate in these patients. Moreover, tumor size greater than or less than 0.5 cm was not a significant determinant of the extent of surgery in patients with PTMC.

Robotic versus Endoscopic Thyroidectomy for Thyroid Cancers: A Multi-Institutional Analysis of Early Postoperative Outcomes and Surgical Learning Curves

Robotic thyroidectomy is an emerging technique with postoperative outcomes that are at least comparable to those of conventional endoscopic thyroidectomy, with some end-points appearing superior. Our multicenter series represents the largest comparison of robotic and endoscopic thyroidectomy to date, with results suggesting a comparable robot technology we used that could overcome some of the technical limitations associated with conventional endoscopic procedures, with reduced operation times and increased lymph node retrieval. Moreover, we found that the learning curve for robotic thyroidectomy was shorter than that for endoscopic thyroidectomy.

Current status of robotic thyroidectomy and neck dissection using a gasless transaxillary approach.

Purpose of review To describe refinements in surgical techniques using robotic thyroidectomy and robotic modified radical neck dissection (MRND), and to discuss the impact of such developments on thyroid cancer management, from oncological, functional, and surgical viewpoints. Recent findings From 2009 to present, 23 reports, including three multicenter trials, on the conduct of robotic thyroid surgery via a gasless transaxillary approach appeared. Twenty-two studies discussed robotic thyroidectomy, whereas one described robotic MRND. These clinical studies showed that robotic surgery afforded identical or superior levels of surgical radicality and oncologic safety compared to use of conventional open or endoscopic surgery in patients with thyroid carcinomas. In such patients, the clinical benefits of robotic thyroidectomy include excellent cosmetic results, reduced pain, improvement in swallowing function, and low morbidity rates. From the viewpoint of surgeons, robotic surgery shortens the surgical learning curve, and causes less musculoskeletal discomfort compared with the conduct of open or endoscopic surgery. Summary The accumulated evidence to date suggests that robotic thyroidectomy and MRND can benefit both patients and surgeons.

Robotic surgery for thyroid disease.

Robotic surgery is an innovation in thyroid surgery that may compensate for the drawbacks of conventional endoscopic surgery. A surgical robot provides strong advantages, including three-dimensional imaging, motion scaling, tremor elimination, and additional degrees of freedom. We review here recent adaptations, experience and applications of robotics in thyroid surgery. Robotic thyroid surgeries include thyroid lobectomy, total thyroidectomy, central compartment neck dissection, and radical neck dissection for benign and malignant thyroid diseases. Most of the current literature consists of case series of robotic thyroidectomies. Recent retrospective and prospective analyses have evaluated the safety and oncologic efficacy of robotic surgery for thyroid cancer. Although robotic thyroid surgery is often associated with longer operation times than conventional open surgery, robotic techniques have shown similar or superior levels of surgical completeness and safety compared with conventional open or endoscopic surgery. Compared to open thyroidectomy, robotic thyroidectomy has been associated with several quality-of-life benefits, including excellent cosmetic results, reduced neck pain and sensory changes, and decreased voice and swallowing discomfort after surgery. For surgeons, robotic surgery has improved ergonomics and has a shorter learning curve than open or endoscopic surgery. The advantages of robotic thyroid surgery over conventional surgery suggest that robotic thyroidectomy with or without neck dissection may become the preferred surgical option for thyroid diseases. Robotic thyroid surgery will likely continue to develop as more endocrine and head-and-neck surgeons are trained and more patients seek this newly developed surgical option.

Relationship of Focally Amplified Long Noncoding on Chromosome 1 (FAL1) lncRNA with E2F Transcription Factors in Thyroid Cancer.

AbstractRecent functional genomic studies revealed that the oncogenic activity of focally amplified lncRNA on chromosome 1 (FAL1, ENSG00000228126) contributes to tumor growth by p21 repression in human cancers. However, the expression of FAL1 was not investigated in papillary thyroid cancer (PTC).We aimed to determine if FAL1 was up-regulated in PTC compared to paired contralateral normal thyroid tissues, and to investigate the potential targets of this lncRNA and its clinicopathological significance in PTC.We analyzed FAL1 and p21 expression levels in 100 PTC samples and matched normal thyroid tissue by qRT-PCR. Using lncRNA microarray data from the Gene Expression Omnibus (accession no. GSE61763), we explored potential targets of FAL1 by Gene Set Enrichment Analysis, followed by verification by qRT-PCR in our PTC samples. A cross-sectional observational study was conducted to investigate the relationship between patients’ clinicopathological features and FAL1 expression.FAL1 expression was significantly higher in PTC than in paired normal thyroid tissues (paired t test, P < 0.001). p21 mRNA expression was also increased, not decreased, in PTC, and had no correlation with FAL1 expression (r = 0.0897, P = 0.4002). Gene Set Enrichment Analysis, using publicly available microarray data, indicated that a gene set related to the cell cycle, including E2F transcription factors 1 and 2, and cyclin D1, was coordinately enriched among samples with high FAL1 expression. A volcano plot showed that E2F1, E2F2, and VEGFA mRNAs were increased in the high FAL1 samples. In clinicopathological analyses, multifocality was more frequently observed in PTC patients with high FAL1 (P = 0.018). Multivariate analysis showed that high FAL1 expression increased the risk of multifocality (after adjustment for clinical variables, OR = 4.019, CI = 1.041–11.020, P = 0.043).FAL1 may have a role in cell-cycle progression and may be associated with aggressive tumor behavior in PTC.

Robotic thyroidectomy learning curve for beginning surgeons with little or no experience of endoscopic surgery.

This study assessed the results of robotic thyroidectomy by fellowship‐trained surgeons in their initial independent practice, and whether standard fellowship training for robotic surgery shortens the learning curve.

Effectiveness of [124I]-PET/CT and [18F]-FDG-PET/CT for Localizing Recurrence in Patients with Differentiated Thyroid Carcinoma

Although the prognosis of patients with differentiated thyroid carcinoma (DTC) is generally encouraging, a diagnostic dilemma is posed when an increasing level of serum thyroglobulin (Tg) is noted, without detection of a recurrent tumor using conventional imaging tools such as the iodine-131 whole-body scanning (the [131I] scan) or neck ultrasonography (US). The objective of the present study was to evaluate the diagnostic value of [124I]-PET/CT and [18F]-FDG-PET/CT in terms of accurate detection of both iodine- and non-iodine-avid recurrence, compared with that of conventional imaging such as the [131I] scan or neck ultrasonography (US). Between July 2009 and June 2010, we prospectively studied 19 DTC patients with elevated thyroglobulin levels but who do not show pathological lesions when conventional imaging modalities are used. All involved patients had undergone total thyroidectomy and radioiodine (RI) treatment, and who had been followed-up for a mean of 13 months (range, 6-21 months) after the last RI session. Combined [18F]-FDG-PET/CT and [124I]-PET/CT data were evaluated for detecting recurrent DTC lesions in study patients and compared with those of other radiological and/or cytological investigations. Nine of 19 patients (47.4%) showed pathological [18F]-FDG (5/19, 26.3%) or [124I]-PET (4/19, 21.1%) uptake, and were classed as true-positives. Among such patients, disease management was modified in six (66.7%) and disease was restaged in seven (77.8%). In particular, the use of the described imaging combination optimized planning of surgical resection to deal with locoregional recurrence in 21.1% (4/19) of patients, who were shown to be disease-free during follow-up after surgery. Our results indicate that combination of [18F]-FDG-PET/CT and [124I]-PET/CT affords a valuable diagnostic method that can be used to make therapeutic decisions in patients with DTC who are tumor-free on conventional imaging studies but who have high Tg levels.