Bilateral choroidal metastasis of follicular thyroid carcinoma 7 years after total thyroidectomy: a case report

ABSTRACT Follicular thyroid cancers account for 15%-20% of all thyroid tumors. Choroidal metastases secondary to follicular thyroid cancer rarely occur. Herein, we report the case of an 85-year-old woman who presented choroidal metastasis from a follicular thyroid carcinoma in the right eye 7 years after total thyroidectomy and underwent enucleation. To confirm the diagnosis and primary tumor site, histopathological, and immunohistochemical examinations were performed. One year later, she presented metastasis in the contralateral eye. Few similar cases have been described in the literature.

Benign cervical schwannoma with tracheal invasion

ABSTRACT Schwannomas commonly develop in the cervical region, 25% - 45% of cases are diagnosed in this anatomical region. Tracheal neurogenic tumors are exceedingly rare and can be misdiagnosed as invasive thyroid carcinomas or other infiltrating malignancies when present at the level of the thyroid gland. Here, we present a case of synchronous benign cervical schwannoma with tracheal invasion and papillary thyroid carcinoma in a patient who was initially hospitalized for COVID-19. The patient presented with dyspnea that was later found to be caused by tracheal extension of a cervical tumor. Surgical excision was performed, and the surgical team proceeded with segmental tracheal resection, removal of the cervical mass, and total thyroidectomy. The specimen was sent for pathological analysis, which revealed synchronous findings of a benign cervical schwannoma with tracheal invasion and papillary thyroid carcinoma. The literature on this subject, together with the present case report, suggests that neurogenic tumors should be included in the differential diagnosis of obstructing tracheal cervical masses. Surgical excision is the first-line of treatment for benign cervical schwannomas.

Administración subcutánea de levotiroxina en hipotiroidismo refractario / Subcutaneous administration of levothyroxine in refrac tory hypothyroidism

Resumen El hipotiroidismo generalmente se puede tratar de manera efectiva con levotiroxina (LT-4) oral. Sin em bargo, el hipotiroidismo refractario al tratamiento con LT-4 es una condición clínica frecuente. Entre las causas se encuentra la falta de adherencia, interacciones con alimentos u otros medicamentos y enfermedades gas trointestinales, como enfermedad inflamatoria intestinal y síndromes de intestino corto. El aumento de la dosis oral de LT-4 no siempre es eficaz en estos escenarios. Por lo tanto, pueden ser necesarias otras vías de administración. En este reporte, evaluamos modalidades alternativas de tratamiento para el hipotiroidismo re fractario y presentamos dos pacientes con malabsorción intestinal tratadas con éxito mediante la administración subcutánea de LT-4.

Abstract Hypothyroidism can usually be treated effectively with oral levothyroxine (LT-4) supplementation. However, hypothyroidism refractory to treatment with LT-4 is a common clinical condition. Causes include poor com pliance, interactions with food or other medications, and gastrointestinal diseases, such as inflammatory bowel disease and short bowel syndromes. Increasing the oral dose of LT-4 is not always effective in these scenarios. Therefore, other routes of administration may be neces sary. In this report, we evaluate alternative treatment modalities for refractory hypothyroidism and present two patients with intestinal malabsorption successfully treated by subcutaneous administration of LT-4.

Cáncer de tiroides en pediatría: a propósito de una entidad poco frecuente

El cáncer de tiroides es una entidad infrecuente en población pediátrica, tiene un conjunto único de características clínicas, patológicas y moleculares en niños. La clínica típica es un nódulo tiroideo de meses de evolución asintomático, como en el caso descrito. En comparación con los adultos, los niños presentan con mayor frecuencia una enfermedad agresiva en etapa avanzada. La conducta de manejo y tratamiento es la cirugía de tiroides radical y el vaciamiento ganglionar amplio, luego yodoterapía y suplencia tiroidea. La supervivencia es excelente, a los 10 años es mayor a 98% sin embargo, se deben recordar las complicaciones relacionadas con el tratamiento de por vida las cuales no son infrecuente.

Thyroid cancer is a rare condition in the pediatric population, it has a unique set of clinical, pathological and molecular characteristics in children. The typical presentation is an asymptomatic thyroid nodule of months of evolution, as in the described case. Compared with adults, children more often present with late-stage aggressive disease. The management and treatment approach is radical thyroid surgery and extensive lymph node dissection, then iodotherapy and thyroid replacement. Survival is excellent, at 10 years it is greater than 98%, however, complications related to lifelong treatment, which are not uncommon, should be kept in mind.

Dependence of radioactive iodine-131 capture by the lacrimal ducts on the tear production level

Purpose: Secondary acquired lacrimal duct obstruction (SALDO) is one of the complications of radioiodine therapy. SALDO is formed a few months after therapy if there is a sufficient uptake of radioactive iodine by the nasolacrimal duct. To date, risk factors leading to SALDO are unclear. The objective was to determine the correlation between the tear production level and radioactive iodine?131 uptake in the lacrimal ducts.Methods: Basal and reflex tear production was studied in 64 eyes prior to the therapy with radioactive iodine?131 after drug?induced hypothyroidism. The condition of the ocular surface was assessed using the Ocular Surface Disease Index (OSDI) questionnaire. Seventy?two hours after the radioactive iodine therapy, scintigraphy was performed, which determined the presence or absence of iodine?131 in the lacrimal ducts. T?statistics and the Mann–Whitney criterion were used to identify the differences between the groups. The differences were considered significant at P ? 0.05. The current tear production level in patients receiving radioiodine therapy was determined using a mathematical model. Results: A statistically significant difference between the basal (p = 0.044) and reflex (p = 0.015) tear production levels was found in cases with and without iodine?131 uptake by the lacrimal ducts. The probable current tear production level corresponds to the sum of basal and 10–20% of reflex tear production. The uptake of iodine?131 was found regardless of the OSDI results.Conclusion: The probability of iodine?131 uptake by the lacrimal ducts rises as the tear production level increases.

Factors influencing the efficacy of residual thyroid clearance with 131I for the first time after surgery in patients with differentiated thyroid cancer / 中国医师杂志

Objective:To explore the influencing factors of residual thyroid clearance with 131I after surgery in patients with differentiated thyroid cancer (DTC). Methods:A retrospective analysis was conducted on the clinical data of 100 DTC patients admitted to the Hunan Provincial People′s Hospital from January 2018 to February 2021 who underwent 131I treatment for the first time. The success rates of first thyroidectomy using different doses of 131I, different pathological types, and different treatment times were compared, and logistic regression analysis was conducted to investigate the influencing factors of the efficacy of first postoperative 131I thyroidectomy in DTC patients. Results:A total of 54 patients successfully cleared residual thyroid, 46 patients failed to clear residual thyroid, and the success rate of clearing residual thyroid was 54%. The success rates of first clearance of residual thyroid in patients with 131I doses of 80 mCi, 90 mCi, and 100 mCi were 37.50%(12/32), 52.78%(19/36), and 71.88%(23/32), respectively, with statistically significant differences among the groups ( P<0.05); The success rates of first removal of residual thyroid in patients with follicular carcinoma, mixed papillary follicular carcinoma, and papillary carcinoma were 65.71%(23/35), 39.13%(9/23), and 52.38%(22/42), respectively. There was no statistically significant difference between the groups ( P>0.05); The success rates of first removal of residual thyroid in the group1 of patients (treatment time<3 months), the group2 of patients (treatment time 3-12 months), and the group3 of patients (treatment time>12 months) were 68.09%(32/47), 44.44%(16/36), and 35.30%(6/17), respectively. There was no statistically significant difference between the groups ( P>0.05); There was no statistically significant difference in the success rate of clearing residual thyroid in DTC patients of different genders, ages, pathological stages, and thyroid stimulating hormone (TSH) levels (all P>0.05); The difference in the success rate of clearing residual thyroid in DTC patients with different metastatic conditions and stimulating thyroid globulin (sTg) was statistically significant (all P<0.05); sTg, postoperative lymph node metastasis, and postoperative distant metastasis were independent risk factors for the efficacy of residual thyroid clearance in DTC patients for the first time after surgery (all P<0.05). Conclusions:The influencing factors for the efficacy of the first 131I in removing residual thyroid include differences in 131I dosage, presence or absence of metastatic lesions during treatment, Tg levels, etc. Reducing Tg levels is an important factor in improving remission rate, and controlling lymph nodes and distant metastasis is a key factor for the successful efficacy of the first 131I in removing residual thyroid.

Clinical value of ultrasound-guided fine-needle aspiration biopsy in the diagnosis of thyroid cancer and assessment of cervical lymph node metastasis / 中国基层医药

Objective:To explore the clinical value of ultrasound-guided fine-needle aspiration biopsy in the diagnosis of thyroid cancer and assessment of cervical lymph node metastasis.Methods:The clinical data of 90 patients with thyroid cancer who received treatment in Zhoushan Hospital from October 2018 to April 2021 were retrospectively analyzed. All patients underwent a two-dimensional ultrasound examination and ultrasound-guided fine-needle aspiration biopsy before surgery. Taking surgical and pathological diagnosis as the gold standard, the efficiency of two-dimensional ultrasound examination versus ultrasound-guided fine-needle aspiration biopsy in the diagnosis of thyroid cancer and cervical lymph node metastasis and in the identification of benign and maligant lymph nodes were investigated. Multivariate Logistic regression analysis was performed to analyze the correlation between different ultrasound signs and the detection rate of lymph nodes. Results:Pathological results showed that among the 90 patients, 73 patients had thyroid cancer, and 17 patients had benign lesions. Ultrasound-guided fine-needle aspiration biopsy results showed that 70 patients had thyroid cancer, and 20 patients had benign lesions, including 4 cases of missed diagnosis and 2 cases of misdiagnosis. The diagnostic sensitivity, specificity, accuracy rate, and Kappa value were 94.52%, 88.24%, 93.33%, and 0.79, respectively. These were highly consistent with the surgical and pathological diagnosis (Kappa value > 0.75). Two-dimensional ultrasound revealed 69 patients with thyroid cancer and 21 patients with benign lesions, including 7 cases of missed diagnosis and 4 cases of misdiagnosis. The diagnostic sensitivity, specificity, accuracy rate, and Kappa value were 90.41%, 76.47%, 87.78%, and 0.63, respectively. Pathological results revealed that cervical lymph node metastasis occurred in 12 patients, and it did not occur in 78 patients. The diagnostic sensitivity, specificity, accuracy rate, and Kappa value of ultrasound-guided fine-needle aspiration biopsy were 83.33%, 97.50%, 95.65%, and 0.81 respectively. These were highly consistent with surgical and pathological results (Kappa value > 0.75). The diagnostic sensitivity, specificity, accuracy rate, and Kappa value of two-dimensional ultrasound examination were 75.00%, 94.87%, 92.22%, and 0.67, respectively. A total of 156 lymph nodes were detected by ultrasound-guided fine-needle aspiration biopsy, including 103 benign lymph nodes and 53 malignant lymph nodes, with a diagnostic accuracy rate of 94.17% and 96.22%, respectively. A total of 173 lymph nodes were detected by two-dimensional ultrasound, including 111 benign lymph nodes and 62 malignant lymph nodes, with a diagnostic accuracy rate of 91.89% and 91.93%, respectively. There were no significant differences in the diagnostic accuracy of benign and malignant lymph nodes between the two examination methods ( χ2 = 0.42, 0.92, both P > 0.05). Multivariate logistic regression analysis showed that hyperechoic masses, cystic lesions, and internal calcification were significantly correlated with the detection rate of lymph nodes diagnosed by two-dimensional ultrasound and ultrasound-guided fine-needle aspiration biopsy ( OR = 6.64, 5.32, 4.12, 7.07, 5.60, 5.06, all P < 0.05). Conclusion:Ultrasound-guided fine-needle aspiration biopsy has high diagnostic efficiency for thyroid cancer and cervical lymph node metastasis. Ultrasound signs of hyperechoic mass, cystic lesions, and internal calcification are significantly correlated with the detection rate of lymph nodes.

Efficacy of routine exposure versus neuromonitoring of superior laryngeal nerve in thyroid cancer surgery / 中国基层医药

Objective:To investigate the efficacy of routine exposure versus neuromonitoring of the external branch of the superior laryngeal nerve (EBSLN) in thyroid cancer surgery. Methods:The clinical data of 500 patients who underwent open thyroid cancer surgery in the Department of Breast and Thyroid Surgery, People's Hospital of Quzhou from July 2017 to June 2020 were retrospectively analyzed. These patients were divided into a monitoring group ( n = 300) and an unmonitored group (control group) ( n = 200) according to whether neuromonitoring was performed during surgery. In the control group, the EBSLN was routinely exposed during the surgery for naked observation. In the monitoring group, the EBSLN was monitored. The Voice Handicap Index score, vocal cord function, and serum levels of parathyroid hormone and calcium ion were compared between the two groups before and after surgery. All patients were followed up for 1 year to observe injury to the EBSLN, parathyroid gland injury, and hypocalcemia. Results:In the monitoring group, operative time (112.32 ± 10.42) minutes, intraoperative blood loss (10.58 ± 5.04) mL, time to extubation (2.07 ± 0.54) days, postoperative drainage flow (10.55 ± 3.58) mL, and postoperative hospital stay (3.03 ± 1.03) days were significantly shorter and less compared with the control group ( t = 18.68, 15.09, 15.24, 32.98, 27.37, all P < 0.001). Compared with before surgery, normalized noise energy, amplitude perturbation, fundamental frequency perturbation, and fundamental frequency value in each group were significantly decreased after surgery, harmonic to noise ratio and the Voice Handicap Index were significantly increased after surgery. These indices were more obviously improved in the monitoring group compared with the control group ( t = 43.31, 27.10, 46.45, 37.11, 8.97, all P < 0.001). Compared with before surgery, serum levels of parathyroid hormone and calcium ion in each group were significantly decreased after surgery. After surgery, serum levels of parathyroid hormone and calcium ion in the control group were significantly lower than those in the monitoring group ( t = 41.14, 5.99, both P < 0.001). The incidence of complications in the monitoring group [4 cases of hypocalcemia (1.33%), 0 cases of parathyroid injury (0.00%), 8 cases of injury to the EBSLN] was significantly lower than that in the control group ( χ2 = 73.41, 74.17, 76.29, all P < 0.001). Conclusion:Neuromonitoring of the EBSLN during open thyroid cancer surgery can effectively improve patient voice and vocal cord function, reduce the rate of injury to the EBSLN, and has a clinical application value.

Effect of dexmedetomidine on cough reactions during recovery from general anesthesia in thyroid tumor surgery / 中华地方病学杂志

Objective:To explore the effect of dexmedetomidine on cough reactions and related indexes during recovery from general anesthesia in thyroid tumor surgery.Methods:A total of 90 patients with thyroid tumor who underwent general anesthesia for thyroid tumor surgery from July 2019 to July 2021 in the First People's Hospital of Shangqiu City, Henan Province were selected and divided into the observation group (45 cases) and the control group (45 cases) according to the random number table method. The observation group was given dexmedetomidine 0.5 μg/kg intravenously at the beginning of the surgery, and the intravenous drip time should not be less than 10 min; the control group was given the same dose of normal saline intravenously. The recovery time and extubation time of the two groups were compared, and the incidence of cough reactions during the recovery from general anesthesia was compared. Changes of visual analogue scale (VAS) of pain at 6 h, 24 h and 48 h after surgery, and the changes of stress response indexes [cortisol (Cor), epinephrine (E) and norepinephrine (NE)] and pain factors [prostaglandin E2 (PGE2), neuropeptide Y (NPY) and β-endorphin (β-EP)] before and 48 h after surgery were compared.Results:The recovery time and extubation time in the observation group [(15.62 ± 3.64), (18.27 ± 4.25) min] were faster than those in the control group [(23.12 ± 4.53), (25.65 ± 3.89) min, P < 0.001]. The incidence of cough reactions during recovery from general anesthesia in the observation group [8.89% (4/45)] was lower than that in the control group [28.89% (13/45), P = 0.015]. The VAS score in the observation group was lower than that in the control group at 6 h, 24 h and 48 h after surgery ( P < 0.001). The levels of serum Cor, E and NE at 48 h after surgery in both groups were higher than those before surgery ( P < 0.001); and the serum Cor, E, and NE levels in the observation group were lower than those in the control group at 48 h after surgery ( P < 0.001). The serum PGE2 and NPY levels of the two groups at 48 h after surgery were higher than those before surgery, while β-EP level was lower than that before surgery ( P < 0.001); the serum PGE2 and NPY levels in the observation group were lower than those in the control group at 48 h after surgery, while β-EP level was higher than that in the control group ( P < 0.001). Conclusion:Dexmedetomidine can reduce the cough reactions during recovery from general anesthesia in thyroid tumor surgery, significantly reduce pain, and has little effect on stress response and pain factors.

Application value of color Doppler ultrasonography combined with thyroid autoantibody detection in early diagnosis of thyroid cancer / 中国医师进修杂志

Objective:To investigate the clinical significance of color Doppler ultrasonography combined with detection of thyroid autoantibodies in the early diagnosis of thyroid cancer.Methods:A total of 108 patients with thyroid cancer who treated in Shaoxing Central Hospital Medical Community General Hospital from September 2019 to September 2021 were selected as the research group, and 108 patients with benign thyroid lesions during the same period were selected as the control group. The ultrasound examination results and the levels of serum thyroglobulin antibody (TgAb), thyroid peroxidase antibody (TPOAb) and thyroid receptor antibody (TRAb) were compared between the two groups. The relationship between the thyroid autoantibodies index and the early diagnosis of thyroid cancer were analyzed by Spearman correlation analysis; the value of early diagnosis by color Doppler ultrasonography combined with detection of thyroid autoantibodies were evaluated by the receiver operating characteristic (ROC) curve.Results:The main features of ultrasonic images in the research group were unclear edge, low echo, irregular shape, chaotic blood flow distribution, internal micro calcification, no envelope and blood flow resistance index ≥0.7. The sensitivity of ultrasonography for the diagnosis of thyroid cancer was 86.11% (93/108), the specificity was 87.18% (102/117) and the accuracy was 90.28% (195/216). The levels of serum TgAb, TPOAb and TRAb in the research group were higher than those in control group: (32.28 ± 2.85) kU/L vs. (21.96 ± 2.54) kU/L, (81.28 ± 7.32) kU/L vs. (51.53 ± 5.86) kU/L, (4.48 ± 1.25) U/L vs. (2.35 ± 0.63 ) U/L, there were statistical differences ( P<0.05). The levels of serum TgAb, TPOAb and TRAb in patients with lymph node metastasis were higher than those in the patients without lymph node metastasis: (36.28 ± 3.12) kU/L vs. (30.60 ± 2.54) kU/L, (93.51 ± 8.57) kU/L vs. (76.13 ± 6.62) kU/L, (5.73 ± 1.54) U/L vs. (3.95 ± 1.12) U/L, there were statistical differences ( P<0.05). The levels of serum TgAb, TPOAb and TRAb in patients with stage Ⅲ-Ⅳ were higher than those in the patients with stage Ⅰ-Ⅱ: (35.84 ± 3.28) kU/L vs. (29.74 ± 2.29) kU/L, (89.35 ± 8.16) kU/L vs. (75.52 ± 6.23) kU/L, (5.28 ± 1.49) U/L vs. (3.91 ± 1.25) U/L, there were statistical differences ( P<0.05). The results of Spearman correlation analysis showed that the levels of serum TgAb, TPOAb and TRAb were positively correlated with lymph node metastasis ( r = 0.758, 0.824, 0.695, P<0.05) and clinical stage of thyroid cancer ( r = 0.735, 0.796, 0.673, P<0.05). The results of ROC curve analysis showed that the area under the curve(AUC) of ultrasound examination combined with TgAb, TPOAb and TRAb for early diagnosis of thyroid cancer was 0.930, the sensitivity was 85.19%, and the specificity was 91.67%. The combined diagnostic value was better than single diagnosis. Conclusions:Ultrasound examination combined with serum TgAb, TPOAb and TRAb has high diagnostic value for early stage thyroid cancer, which is helpful to clinically clarify the condition, and provides a reliable basis for preoperative diagnosis and targeted individualized treatment plan.

Research on BHLHE40 targets HMGA2 to reduce the sensitivity of thyroid cancer cells to cisplatin through activating the oxidative phosphorylation pathway / 国际肿瘤学杂志

Objective:To explore whether BHLHE40 can affect the sensitivity of thyroid cancer (TC) cells to cisplatin by activating oxidative phosphorylation (OXPHOS) pathway by targeting high mobility group A2 (HMGA2) .Methods:The mRNA expression of HMGA2 and its upstream transcription factor BHLHE40 in TC tissues was analyzed by TCGA-THCA and hTFtarget online databases. The si-HMGA2, oe-HMGA2, oe-BHLHE40, negative control si-NC and oe-NC were transfected into TC cells (K1 and SW579) by liposome transfection method. The mRNA expression levels of BHLHE40 and HMGA2 in TC cells (SW579, FTC-133, and K1) and normal thyroid cells (Nthy ori3-1) were detected by real-time quantitative PCR (qRT-PCR). The cell viability was detected by MTT assay, the half inhibitory concentration (IC 50) value of cisplatin was calculated by CCK-8 assay, the apoptosis level was detected by flow cytometry, and the expression of OXPHOS complex was detected by Western blotting. Seahorse XFe 96 was used to analyze the oxygen consumption rate of the TC cells. Dual-luciferase assay and chromatin immunoprecipitation (ChIP) assay were used to analyze the binding relationship between BHLHE40 and HMGA2. Results:TCGA database results showed that the mRNA expression levels of HMGA2 and BHLHE40 in TC tissues (10.57±2.58, 13.89±1.13) were higher than those in normal thyroid tissues (4.82±1.69, 12.28±1.01), with statistically significant differences ( t=16.69, P<0.001; t=10.43, P<0.001). The results of qRT-PCR showed that the relative mRNA expression levels of HMGA2 in normal thyroid cells (Nthy ori3-1) and TC cells (SW579, FTC-133, and K1) were 1.00±0.13, 2.94±0.23, 4.71±0.41 and 6.29±0.49, while those of BHLHE40 were 1.00±0.12, 2.60±0.23, 3.39±0.35 and 6.18±0.51 respectively, both with statistically significant differences ( F=130.50, P<0.001; F=125.20, P<0.001). Further pairwise comparison showed that mRNA expression levels of HMGA2 and BHLHE40 in TC cells were significantly higher than those in normal thyroid cells (all P<0.001). According to MTT experimental results, si-HMGA2 treatment significantly reduced the cell viability of K1 cells compared to the si-NC group (all P<0.05). In addition, compared to the oe-NC group, oe-HMGA2 treatment significantly increased the cell viability of SW579 cells (all P<0.05). Compared to the oe-NC+DMSO group, the oe-HMGA2+DMSO group showed enhanced cell viability of SW579 cells, while the OXPHOS pathway inhibitor Gboxin was able to reverse the effect of overexpressing HMGA2 on cell viability (all P<0.05). The results of flow cytometry and CCK-8 experiments showed that compared to the si-NC group (apoptosis level: 6.19%±0.28%; cisplatin IC 50 value: 17.47 μmol/L), knocking down HMGA2 could increase the apoptosis level (11.96%±0.32%; t=19.17, P<0.001) and cisplatin sensitivity (IC 50 value: 1.49 μmol/L) of K1 cells. In addition, compared to the oe-NC group (apoptosis level: 9.98%±0.32%; cisplatin IC 50 value: 8.17 μmol/L), overexpressing HMGA2 significantly decreased the apoptosis level (4.32%±0.25%; t=19.65, P<0.001) and cisplatin sensitivity (IC 50 value: 34.95 μmol/L) of SW579 cells. The results of dual-luciferase assay showed that compared with the si-NC group, knocking down the expression of BHLHE40 in human kidney epithelial 293T cells significantly reduced the luciferase activity of wild-type HMGA2 (0.31±0.02 vs. 1.00±0.11; t=10.69, P=0.004). However, there was no significant effect on the luciferase activity of mutant-type HMGA2 (1.06±0.11 vs. 1.00±0.07; t=0.80, P=0.470). ChIP results showed that the mRNA expression level of HMGA2 in K1 cells was significantly increased in the anti-BHLHE40 group (6.57±0.62) compared with the IgG group (1.00±0.10; t=15.36, P<0.001). Compared to the oe-NC+DMSO group, the oe-HMGA2+DMSO group showed decreased apoptosis level ( P<0.05) and cisplatin sensitivity of SW579 cells, with a significant increase in the expression of OXPHOS complexes Ⅰ-Ⅴ and cellular oxygen consumption rates (all P<0.05). The effect of overexpressing HMGA2 was reversed by treatment with oe-HMGA2+Gboxin (all P<0.05). The recovery experiment showed that compared to the oe-NC+si-NC group, overexpression of BHLHE40 in SW579 cells increased cell viability and the expression of OXPHOS complexes Ⅰ-Ⅴ, while decreasing apoptosis levels and increasing cellular oxygen consumption rates and cisplatin IC 50 values (all P<0.05). However, simultaneous knockdown of HMGA2 reversed the effect of overexpressing BHLHE40 (all P<0.05) . Conclusion:BHLHE40 can activate the OXPHOS pathway by targeting and regulating the expression of HMGA2, thereby affecting the sensitivity of TC cells to cisplatin.

Clinical application of robotic surgical system in re-operation of thyroid cancer / 国际外科学杂志

Objective:To investigate the feasibility, safety and effectiveness of Da Vinci robotic surgical system in the reoperation of recurrent or residual thyroid cancer.Methods:Retrospective analysis was performed on the clinical data of 9 patients with Da Vinci robot-assisted reoperation for thyroid cancer in the 960th Hospital of the People′s Liberation Army of China from September 2018 to January 2022, the operation time, number of lymph nodes dissected, intraoperative blood loss, length of hospital stay, total postoperative drainage volume, incidence of complications, satisfaction with postoperative aesthetic effect, visual analyogue scale (VAS) score at the 24 h after surgery and number of recurrence during follow-up were counted.Results:The surgery time of 9 cases was (186.67±44.44) min, the number of lymph nodes cleared were (15.77±13.59), intraoperative blood loss was (21.11±16.91) mL, hospital stay were (10.67±3.32) days, total postoperative drainage was (286.94±90.85) mL. There was no complications, and all patients were satisfied with the postoperative cosmetic effect whose VAS score was (8.22±1.09), and VAS score was 0 to 3 (2.44±0.73) points, no recurrence during the follow-up period from 6 to 46 months.Conclusion:With adequate preoperative evaluation and an experienced surgeon team, the use of robots in recurrent or residual thyroid cancer resurgery is feasible, safe and effective.

A retrospective cohort study of total areolar endoscopic approach versus open thyroidectomy for the treatment of papillary thyroid carcinoma / 国际外科学杂志

Objective:To compare the effectiveness of areola approach endoscopic thyroidectomy (AET) and conventional open thyroidectomy (OT) in treating papillary thyroid carcinoma.Methods:Four hundred and twenty-eight female patients with papillary thyroid carcinoma who were treated at the Department of General Surgery, Beijing Friendship Hospital between January 2017 and January 2020 were included according to the inclusion and exclusion criteria, of whom 183 underwent AET (AET group) and 245 underwent OT (OT group). Direct comparison and subsequent propensity score matching methodology were utilized to compare the differences between the two operation methods in terms of surgical time, intraoperative parathyroid transplantation rate, intraoperative nerve injury, postoperative complications, reoperation rate, number of lymph node dissections, postoperative lymph node metastasis at 2 years, and route tumor implantation. Data analysis was performed by using SPSS 25.0 software. The metric data of normal distribution was represented by mean ± standard deviation ( ± s), and the t-test was used for between-group comparison. The Chi-test was used for between-group comparison of count data. Results:The AET group had an age of (38.89±9.08) years, weight of (62.10±10.45) kg, and height of (161.97±5.31) cm; the OT group had an age of (45.88±12.47) years, weight of (65.11±12.72) kg, and height of (161.62±5.24) cm. The differences in age, weight, and body mass index between the two groups were statistically significant ( P<0.05). The surgical time in the AET group was (183.00±137.22) min, which was significantly longer than (87.94±28.25) min of the OT group ( t=16.67, P<0.001). The parathyroid transplantation rate in the OT group was significantly higher than that in the AET group (49.39% vs 34.97%, χ2=8.87, P=0.003). There were no statistically significant differences between the two groups in terms of intraoperative nerve injury, postoperative complications, reoperation rate, number of lymph node dissections, postoperative lymph node metastasis at 2 years, and route tumor implantation. After propensity score matching based on differences in age, weight, body mass index, and soon, 183 cases of AET (AET-PS group) and OT (OT-PS group) were obtained for statistical analysis. The surgical time in the AET-PS group was (137.22±32.77) min, which was significantly longer than (90.26±29.35) min of the OT-PS group ( t=14.44, P<0.001). The parathyroid transplantation rate in the OT-PS group was significantly higher than that in the AET-PS group (53.01% vs. 34.97%, χ2=12.08, P=0.001). There were no statistically significant differences between the two groups in terms of intraoperative nerve injury, postoperative complications, reoperation rate, number of lymph node dissections, postoperative lymph node metastasis at 2 years, and route tumor implantation. Conclusions:AET and OT are equally safe and effective in treating papillary thyroid carcinoma. AET surgery can be performed safely and feasibly under strict adherence to surgical principles.

Clinicopathological analysis of superior mediastinal lymph node metastases in medullary thyroid carcinoma / 中华肿瘤杂志

Objective: To investigate the clinicopathological characteristics of superior mediastinal lymph node metastases (sMLNM) in medullary thyroid carcinoma (MTC). Methods: This retrospective analysis enrolled the patients who were treated for sMLNM of MTC in our hospital from May 2012 to January 2021. All patients were suspected of sMLNM due to preoperative imaging. According to the pathological results, the patients were divided into two groups named sMLNM group and the negative superior-mediastinal-lymph-node group. We collected and analyzed the clinical features, pathological features, pre- and post-operative calcitonin (Ctn), and carcinoembryonic antigen (CEA) levels of the two groups. Logistic regression analysis was used to analyze risk factors, and receiver operation characteristic (ROC) curves were drawn to determine the optimal cut-off values of preoperative Ctn and preoperative CEA for predicting sMLNM. Results: Among the 94 patients, 69 cases were in the sMLNM group and 25 cases were in the non-SMLNM group. Preoperative Ctn level (P=0.003), preoperative CEA level (P=0.010), distant metastasis (P=0.022), extracapsular lymph node invasion (P=0.013), the number of central lymph node metastases (P=0.002) were related to sMLNM, but the multivariate analysis did not find any independent risk factors. The optimal threshold for predicting sMLNM by pre-operative Ctn is 1500 pg/ml and AUC is 0.759 (95% CI: 0.646, 0.872). The sensitivity, specificity, positive predictive value, and negative predictive value of diagnosis are 61.2%, 77.3%, 89.1%, 39.5%, respectively. In patients who underwent mediastinal lymph node dissection through transsternal approach, the metastatic possibility of different levels from high to low were level 2R (82.3%, 28/34), level 2L (58.8%, 20/34), level 4R (58.8%, 20/34), level 3 (23.5%, 8/34), level 4L (11.8%, 4/34). Postoperative complications occurred in 41 cases (43.6%), and there was no perioperative death in all cases. 14.8% (12/81) of the patients achieved biochemical complete response (Ctn≤12 pg/ml) one month after surgery, 5 of these patients were in sMLNM group. Conclusions: For patients who have highly suspicious sMLNM through imaging, combining with preoperative Ctn diagnosis can improve the accuracy of diagnosis, especially for patients with preoperative Ctn over 1 500 pg/ml. The superior mediastinal lymph node dissection for the primary sternotomy should include at least the superior mediastinal levels 2-4 to avoid residual lesions. The strategy of surgery needs to be cautiously performed. Although the probability of biochemical cure in sMLNM cases is low, nearly 40% of patients can still benefit from the operation at the biochemical level.

Analysis of risk factors for recurrence of differentiated thyroid carcinoma after surgical resection combined with iodine-131 and TSH suppression therapy / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the risk factors of recurrence after surgical resection of differentiated thyroid carcinoma combined with iodine-131 and TSH（Thyroid stimulating hormone） inhibition therapy. Methods:From January 2015 to April 2020, the clinical data of patients with structural recurrence and without recurrence were retrospectively collected after surgical treatment combined with iodine-131 and TSH inhibition therapy in the First Medical Center of PLA General Hospital. The general conditions of the two groups of patients were analyzed and the measurement data in line with the normal distribution was used for comparison between groups. For measurement data with non-normal distribution, the rank sum test was used for inter-group comparison. The Chi-square test was used for comparison between the counting data groups. Univariate and multivariate regression analyses were used to determine the risk factors associated with relapse. Results:The median follow-up period was 43 months（range 18-81 months） and 100 patients（10.5%） relapsed among the 955 patients. Univariate analysis showed that tumor size, tumor multiple, the number of lymph node metastases>5 in the central region of the neck, and the number of lymph node metastases>5 in the lateral region were significantly correlated with post-treatment recurrence（P<0.001, P=0.018, P<0.001, P<0.001）. Multivariate analysis showed that tumor size（adjusted odds ratio OR: 1.496, 95%CI: 1.226-1.826, P<0.001）, tumor frequency（adjusted odds ratio OR: 1.927, 95%CI: 1.003-3.701, P=0.049）, the number of lymph node metastases in the central neck region>5（adjusted odds ratio OR: 2.630, 95%CI: 1.509-4.584, P=0.001） and the number of lymph node metastases in the lateral neck region>5（adjusted odds ratio OR: 3.074, 95%CI: 1.649-5.730, P=0.001） was associated with tumor recurrence. Conclusion:The study showed that tumor size, tumor multiple, the number of lymph node metastases in the central region of the neck>5 and the number of lymph node metastases in the side of the neck >5 are independent risk factors for recurrence of differentiated thyroid cancer after surgical resection combined with iodine-131 and TSH inhibition therapy.

Clinical study of bilateral axillo-breast approach robot in obese women with thyroid cancer / 临床耳鼻咽喉头颈外科杂志

Objective:To explore the safety and feasibility of bilateral axillo-breast approach （BABA） robot in the operation of thyroid cancer in obese women. Methods:The clinical data of 81 obese female patients who underwent da Vinci robotic thyroid cancer surgery（robotic group） at the Department of Thyroid and Breast Surgery, PLA 960 Hospital from May 2018 to December 2021 were retrospectively analyzed and compared with the clinical data of 106 obese female thyroid cancer patients who underwent open surgery（open group） during the same period. The age, body mass index（BMI）, mean time of surgery, mean postoperative drainage, tumor diameter, postoperative tumor stage, number of lymph node dissection in the central and lateral cervical regions, number of positive lymph nodes in the central and lateral cervical regions, postoperative cosmetic outcome satisfaction score, mean postoperative hospital stay and postoperative complications of all patients were counted. The results were analyzed using SPSS 26.0 statistical software, and the count data were compared using the χ² test, and the measurement data were compared using the t test. Results:All patients completed the operation successfully, and there was no conversion in the robot group, postoperative pathological results were all composed of papillary thyroid carcinoma. The operation time in the robot group was（144.62±36.38） min, which was longer than that in the open group（117.06±18.72） min（P<0.05）. The average age of the robot group was（40.25±9.27） years, which was lower than that of the open group（49.59±8.70） years（P<0.05）. The satisfactory score of cosmetic effect in the robot group（9.44±0.65） was higher than that in the open group（5.23±1.07）（P<0.05）. There was no significant difference in tumor diameter, BMI, average postoperative drainage, temporary hypoparathyroidism and recurrent laryngeal nerve injury, number of central and lateral cervical lymph node dissection, number of positive lymph nodes in the central and lateral cervical regions, and average postoperative hospital stay between the two groups. There was no permanent hypoparathyroidism and recurrent laryngeal nerve injury in both groups. Conclusion:The application of BABA pathway robot in thyroid cancer surgery in obese women is safe and feasible, and the cosmetic effect is better after operation.

Metastatic diffuse follicular variant papillary thyroid cancer without cervical lymph node metastasis presenting with symptoms related to hypopituitarism

ABSTRACT In this article, we present a case of diffuse follicular variant papillary thyroid carcinoma with pituitary metastasis, which is a rare cause of pituitary metastasis. The follicular variant of papillary thyroid carcinoma is an uncommon variant of papillary carcinoma. A 74-year-old male was presented with weakness, fatigue, and a decreased appetite. The patient was diagnosed with secondary adrenal and thyroid insufficiencies. Imaging revealed a pituitary mass with suprasellar extension, right cavernous sinus invasion, and optic chiasm compression. Thyroid ultrasonography revealed a nodule with a maximum size of 7.2cm in the right lobe. Cytological examination via fine-needle aspiration suggested papillary thyroid cancer. Total thyroidectomy with central and right lateral neck dissection confirmed the diagnosis of diffuse follicular variant of papillary thyroid carcinoma. Owing to visual field defects, the patient underwent transsphenoidal surgery. Histological and immunohistochemical evaluations confirmed pituitary metastasis from the papillary thyroid cancer. Radioactive iodine treatment and gamma knife radiotherapy of the pituitary gland were performed. The initiation of sorafenib treatment was deemed appropriate during the follow-up. A significant decrease in the thyroglobulin levels was observed after sorafenib treatment. Pituitary metastasis should be considered in patients diagnosed with hypopituitarism and pituitary lesions at initial evaluation. The presence of visual field defects may be an indication for neurosurgical intervention and guide both diagnosis and treatment. The management of papillary thyroid cancer and the role of treatment modalities in prognosis depend on the biological behavior of the tumor. Early diagnosis and multidisciplinary management are crucial for the treatment of these patients.

Correlation between thyroid fine needle aspiration and pathological examination: a 10 year retrospective study

ABSTRACT Objective To establish the diagnostic performance of fine-needle aspiration in detecting benign and malignant neoplasm in comparison with post-thyroidectomy histopathological findings among patients who received a thyroidectomy. Methods Retrospective observational data collected between 2011-2021 were included from patients who received partial or total thyroidectomy. The Bethesda system was used to classify neoplasms from fine-needle aspiration procedures as benign or malignant. Sample characteristics, diagnostic accuracy, sensitivity, specificity, and predictive values were evaluated. Results Patients (n=360) who underwent thyroidectomy were analyzed, of whom 142 (39.4%) and 218 (60.6%) had benign and malignant neoplasms, respectively. Using the Bethesda system, 23 (6.4%) were classified as unsatisfactory result (BI), 83 (23.1%) as benign (BII), 50 (13.9%) as atypia of undetermined significance (BIII), 23 (6.4%) as suspected follicular or Hürthle cell neoplasia (BIV), 102 (28.3%) as suspected malignancy (BV) and 79 (21.9%) as malignant (BVI). The fine-needle aspiration diagnostic accuracy for carcinomas was 92%, while the sensitivity and specificity were 94.4% and 86.9%, respectively. The negative and positive predictive values were 87.9% and 93.9%, respectively. Conclusion Fine-needle aspiration has high diagnostic accuracy, sensitivity and specificity, and is a reliable test for distinguishing between benign and malignant thyroid pathologies.

Does a three-degree hypoechogenicity grading improve ultrasound thyroid nodule risk stratification and affect the TI-RADS 4 category? A retrospective observational study

ABSTRACT Objective: The aim of this study was to determine whether classifying hypoechogenicity in three degrees (mild, moderate, and marked) could improve the distinction between benign and malignant nodules and whether such an approach could influence Category 4 of the Thyroid Imaging Reporting and Data System (TI-RADS). Materials and methods: In total, 2,574 nodules submitted to fine needle aspiration, classified by the Bethesda System, were retrospectively assessed. Further, a subanalysis considering solid nodules without any additional suspicious findings (n = 565) was performed with the purpose of evaluating mainly TI-RADS 4 nodules. Results: Mild hypoechogenicity was significantly less related to malignancy (odds ratio [OR]: 1.409; CI: 1.086-1.829; p = 0.01), compared to moderate (OR: 4.775; CI: 3.700-6.163; p < 0.001) and marked hypoechogenicity (OR: 8.540; CI: 6.355-11.445; p < 0.001). In addition, mild hypoechogenicity (20.7%) and iso-hyperechogenicity (20.5%) presented a similar rate in the malignant sample. Regarding the subanalysis, no significant association was found between mildly hypoechoic solid nodules and cancer. Conclusion: Stratifying hypoechogenicity into three degrees influences the confidence in the assessment of the rate of malignancy, indicating that mild hypoechogenicity has a unique low-risk biological behavior that resembles iso-hyperechogenicity, but with minor malignant potential when compared to moderate and marked hypoechogenicity, with special influence on the TI-RADS 4 category.

Ultrasound in cervical traumatic neuromas after neck dissection in thyroid carcinoma patients: descriptive analysis and diagnostic accuracy

ABSTRACT Objective: Cervical traumatic neuromas (CTNs) may appear after lateral neck dissection for metastatic thyroid carcinoma. If they are misdiagnosed as metastatic lymph nodes (LNs) in follow-up neck ultrasound (US), unnecessary and uncomfortable fine-needle aspiration biopsy are indicated. The present study aimed to describe US features of CTNs and to assess the US performance in distinguishing CTNs from abnormal LNs. Subjects and methods: Retrospective evaluation of neck US images of 206 consecutive patients who had lateral neck dissection as a part of thyroid cancer treatment to assess CTN's US features. Diagnostic accuracy study to evaluate US performance in distinguishing CTNs from abnormal LNs was performed. Results: Eight-six lateral neck nodules were selected for analysis: 38 CTNs and 48 abnormal LNs. CTNs with diagnostic cytology were predominantly hypoechogenic (100% vs. 45%; P = 0.008) and had shorter diameters than inconclusive cytology CTNs: short axis (0.39 cm vs. 0.50 cm; P = 0.03) and long axis (1.64 cm vs. 2.35 cm; P = 0.021). The US features with the best accuracy to distinguish CTNs from abnormal LNs were continuity with a nervous structure, hypoechogenic internal lines, short/long axis ratio ≤ 0.42, absent Doppler vascularization, fusiform morphology, and short axis ≤ 0.48 cm. Conclusion: US is a very useful method for assessing CTNs, with good performance in distinguishing CTNs from abnormal LNs.