June Young Choi

Surgical completeness of bilateral axillo-breast approach robotic thyroidectomy: Comparison with conventional open thyroidectomy after propensity score matching

BACKGROUND Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) has good postoperative and excellent cosmetic outcomes. To assess the surgical completeness of BABA RoT, it was compared to open thyroidectomy (OT) after propensity score matching of the cohorts. METHODS Between 2008 and 2010, 760 patients who underwent total thyroidectomy with central node dissection (CND) caused by papillary thyroid carcinoma (PTC) in Seoul National University Hospital were enrolled; 327 BABA robotic and 423 open method operations were performed. We selected 174 robotic and 237 open thyroidectomy patients who received radioactive iodine (RAI) ablation. Propensity score matching using 3 demographic and 5 pathologic factors was used to generate 2 matched cohorts, each composed of 108 patients. RESULTS The matched BABA RoT and OT cohorts were not different with regard to the RAI uptake ratio, stimulated thyroglobulin (Tg) levels, or proportion of patients with stimulated Tg levels <1.0 ng/mL on the first ablation. The number of RAI ablation sessions and RAI doses needed to achieve a complete ablation also did not differ significantly. CONCLUSION The surgical completeness of BABA RoT did not differ from OT. BABA RoT may be suitable for patients with PTC who prefer scarless neck surgery.

Bilateral axillo-breast approach robotic thyroidectomy.

Background: Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) has good postoperative and excellent cosmetic outcomes. This study aimed to describe the techniques for robotic BABA thyroidectomy in detail (see Videos, Supplemental Digital Content 1, http://links.lww.com/SLE/A45 and Supplemental Digital Content 2, http://links.lww.com/SLE/A46). Methods: Between 2008 and 2010, 704 patients underwent BABA RoT. The mean patient age was 38.9±9.1 years and the male-to-female ratio was 1:8.0. BABA RoT is an oncoplastic thyroid surgery using BABA and da Vinci robot system with low pressure of CO2 gas insufflations. Results: The operation types were as follows: total thyroidectomy with or without neck dissection (n=556, 78.9%), subtotal thyroidectomy (n=67, 9.5%), lobectomy (n=73, 10.4%), and completion thyroidectomy (n=8, 1.1%). Conclusions: BABA RoT yields good postoperative outcomes. With excellent cosmetic outcomes, this technique may be a suitable alternative for patients with thyroid diseases.

BRAF(V600E) Is Correlated with Recurrence of Papillary Thyroid Microcarcinoma: A Systematic Review, Multi-Institutional Primary Data Analysis, and Meta-Analysis.

BACKGROUND Given the increasing incidence of papillary thyroid carcinoma despite stable disease-specific mortality rates, the potential for the disease to reoccur is a key outcome to predict. The BRAF(V600E) mutation has been associated with recurrent disease in larger tumors. However, its correlation in papillary thyroid microcarcinoma (PTMC) is not clear in individual series. METHODS The MEDLINE, EMBASE, Web of Science, and Cochrane databases were searched for studies including patients with PTMC undergoing initial surgical treatment. Studies with at least two years of follow-up, BRAF genotyping (the comparator), and recurrence as an outcome were included, as were unpublished primary data on 485 patients from two institutions. The metameter analyzed was odds ratio (OR) for recurrence between patients with BRAF(V600E) versus BRAF wild type (BRAFwt). RESULTS The initial search identified 431 references. After screening of the abstracts for inclusion, 44 manuscripts were reviewed in full by two independent reviewers. Four published studies and primary data from two institutional cohorts were included in the final analysis. A meta-analysis of 2247 PTMC patients revealed that patients with a BRAF(V600E) mutation had a higher likelihood for recurrence (odds ratio 2.09 [confidence interval 1.31-3.33], p = 0.002). CONCLUSIONS This meta-analysis shows that BRAF mutational status correlates with recurrence of PTMCs, highlighting the potential utility of genotyping in preoperative and postoperative planning. BRAF mutation may be helpful in risk-stratifying patients with PTMC for surgical management versus observation.

Comparison of 4D CT, Ultrasonography, and 99mTc Sestamibi SPECT/CT in Localizing Single-Gland Primary Hyperparathyroidism

Objective The present study was designed to evaluate 4D computerized tomography (CT) as a means of localizing abnormal parathyroid glands in primary hyperparathyroidism (HPT). Study Design Case series with expertized image review. Setting Tertiary care hospital. Subjects and Methods A total of 38 patients were recruited for study, all of whom had undergone focused parathyroidectomy for single-lesion primary HPT between June 2011 and September 2013. In each patient, 3 imaging procedures were performed: cervical ultrasonography (US), 99mTc-sestamibi SPECT/CT (SeS), and 4D CT. Collective imaging data were blindly reviewed and compared. Results 4D CT outperformed US and SeS in terms of sensitivity (P = .27), specificity (P = .01), positive predictive value (PPV) (P < .01), negative predictive value (NPV) (P = .19), and accuracy (P < .01). In 7.9% (3/38) of patients, 4D CT provided specific anatomic information that was unaffordable by US and SeS. Localization by 4D CT correlated with tissue parathyroid hormone level (P = .02), maximum diameter (P = .01), and volume (P < .01) of abnormal parathyroid glands. Conclusion 4D CT proved helpful in localizing target parathyroid glands of primary HPT that were missed by traditional imaging.

A novel lateral-approach laryngeal ultrasonography for vocal cord evaluation

BACKGROUND Laryngeal ultrasonography (LUS) is a new method of vocal cord (VC) evaluation in patients with risk of vocal cord palsy (VCP). The previously described anterior-approach LUS reportedly, however, has high failure rate of VC visualization in male patients. We devised a novel lateral-approach LUS to overcome this limitation. METHODS A total of 382 (82 male, 300 female) consecutive LUS and direct laryngoscopy (DL) examinations were performed on perioperative thyroidectomy and parathyroidectomy patients. The anterior-approach LUS was used for female patients whereas the lateral-approach LUS was used for male patients. Findings were cross-validated independently with DL examinations. RESULTS Both anterior and lateral LUS methods had 100% visualization rate (no failed visualization) with an overall sensitivity of 100% (23/23) and specificity of 99.2% (356/359) for VCP. Among the 300 female patients, 18 patients had VCP. Sensitivity and specificity of anterior-approach LUS were 100% (18/18) and 99.3% (280/282), respectively. Among the 80 male patients, 5 patients had VCP. Sensitivity and specificity of lateral-approach LU were 100% (5/5) and 98.7% (76/77), respectively. CONCLUSION The new LUS approach significantly enhances the visualization of vocal cords and, therefore, overall diagnostic efficacy of LUS in male patients.

A comparative study of postoperative pain for open thyroidectomy versus bilateral axillo-breast approach robotic thyroidectomy using a self-reporting application for iPad

Purpose Postoperative pain for robotic thyroid surgeries including bilateral axillo-breast approach (BABA) has not been well studied. In this study, we have developed a self-reporting application (SRA) for iPad and prospectively collected pain scores from open thyroidectomy (OT) and BABA robotic thyroidectomy (RT) patients. Methods Female patients who underwent total thyroidectomy for papillary thyroid carcinoma were included. Patients recorded pain scores for throat, anterior neck, posterior neck, chest, and back on postoperative days 1, 2, and 3. Once discharged, on postoperative day 14, a survey was also conducted on satisfaction of SRA and cosmesis. Results A total of 54 patients were enrolled (27 BABA RT and 27 OT). There were no significant differences between the 2 groups in clinicopathological characteristics and postoperative complication rates. Postoperative pain scores at days 1, 2, 3, and 14 were not significantly different between the groups for throat, anterior neck, posterior neck, or back. Postoperative analgesic requirements were similar between the 2 groups. Wound satisfaction scores were significantly higher in the BABA RT group (BABA RT 7.4 vs. OT 5.7; P = 0.016). Satisfaction scores for the usefulness of SRA were above 7.2 for all four questionnaire items on the 10-point scale. Conclusion Postoperative pain for BABA RT is equivalent to OT but offers greater cosmetic satisfaction for patients. A mobile device application such as SRA may facilitate proper assessment and management of pain in postoperative patients.

Clinicopathological characteristics and treatment outcomes of 38 cases of primary thyroid lymphoma: a multicenter study

Purpose Primary thyroid lymphoma (PTL) is a rare disease and it has been investigated in a limited number of studies. The present multicenter study evaluated the clinical features and treatment outcomes of PTL. Methods The medical records of patients diagnosed with PTL between 2000 and 2013 in three centers were retrospectively reviewed. Results The study included 11 men and 27 women with a median age of 63.3 years (range, 42-83 years). The median follow-up was 56.0 months (range, 3-156 months). Of the 38 patients included, 16 had mucosa-associated lymphoid tissue (MALT) lymphoma, six had mixed MALT and diffuse large B-cell lymphoma (DLBCL), and 16 had DLBCL. Thirty-five patients (92.1%) had early stage (stage I/II) disease. Of the 16 MALT lymphoma patients, 14 were treated by surgery, and radiotherapy (RT) or chemotherapy was combined in five patients. Two patients received RT or chemotherapy alone. Of the six mixed MALT and DLBCL patients, three underwent surgery with chemotherapy and three underwent chemotherapy alone, RT alone, or surgery with RT. All of the 16 DLBCL patients received chemotherapy, and surgery and RT was combined in 4 and 1 patients, respectively. The 5-year survival was 100% for MALT lymphoma (7 of 7) and mixed MALT and DLBCL patients (5 of 5) and 87.5% for DLBCL patients (7 of 8). Conclusion Early stage PTL has an excellent prognosis when managed by single or combined treatment modalities. Clinicians should consider PTL in patients with underlying Hashimotos thyroiditis presenting with an enlarging thyroid mass.

An exclusively dopamine secreting paraganglioma in the retroperitoneum: a first clinical case in Korea

Exclusively dopamine producing retroperitoneal paragangliomas are extremely rare. We have experienced the first Korean case managed successfully based on the proper evaluation. A 26-year-old female patient came to our attention after the accidental detection of an adrenal mass. She had no symptoms and denied any family history. Laboratory evaluations were normal but serum dopamine (425 ng/L) and 24-hour urine dopamine levels (1,565.3 µg/day) were elevated. She underwent laparoscopic right adrenalectomy. Histopathological diagnosis was a paraganglioma. After operation, dopamine levels in serum and 24-hour urine dropped to 0.09 ng/L and 388.4 µg/day. Dopamine producing paraganglioma elicit no clinical symptoms. Only the dopamine level is elevated in serum and 24-hour urine samples. Surgical resection without using preoperative alpha blockage is the treatment of choice. The prognosis for patients with this tumor tends to be poor because the diagnosis is usually delayed due to lack of symptoms.

Combined effect of Hashimoto's thyroiditis and BRAFV600E mutation status on aggressiveness in papillary thyroid cancer

The purpose of this study was to evaluate the association between Hashimotos thyroiditis and BRAFV600E mutation status in patients with papillary thyroid cancer (PTC) and to determine their combined association with tumor aggressiveness in PTC.

In-Depth Survey of Scarring and Distress in Patients Undergoing Bilateral Axillo-Breast Approach Robotic Thyroidectomy or Conventional Open Thyroidectomy.

Purpose: Oncologic and surgical outcomes of bilateral axillo-breast approach (BABA) robotic thyroidectomy (RoT) are comparable with those of open thyroidectomy (OT). We compared degree of scarring and psychological/physical distress between OT and BABA RoT. Materials and Methods: Study included 129 cases of thyroidectomy (78 OT, 51 BABA RoT). Patients were evaluated by psychology consultant using 5-point scale questionnaire. Results: BABA RoT was associated with lower degree of scarring than OT (7.8 vs. 11.7, P<0.001). Psychological distress immediately after operation and during surveillance period was higher in OT than in BABA RoT (3.1 vs. 2.6, P=0.009 and 2.4 vs. 1.9, P<0.001). Physical distress (pain and exercise limitation) did not differ between groups (2.5 vs. 2.6, P=0.321 and 2.0 vs. 1.9, P=0.0175). Conclusions: BABA RoT was associated with less scarring and psychological distress than OT. BABA RoT might be alternative for patients who are concerned about neck scar.