Safety and cost-effectiveness of outpatient thyroidectomy: A retrospective observational study.

OBJECTIVES: To investigate the safety and cost-effectiveness of outpatient thyroidectomy and provide a systematic postoperative protocol for safe discharge. METHODS: In this retrospective review, the medical records of all patients who underwent total, hemi, or completion thyroidectomy from July 2017 to April 2019 at 2 tertiary care hospitals were reviewed. Multivariable analysis was performed on the potential predictors of postoperative complications. Healthcare costs were calculated by the type of admission based on the average costs at the 2 centers. RESULTS: One hundred twenty-two patients were enrolled in this study. The majority of cases were in the outpatient group (n=76, 62.3%). Total thyroidectomy was the most prevalent type of surgery (n=90, 73.7%). There were a total of 20 complications in 18 patients (inpatient=9 versus [vs.] outpatient=9). No cases of cervical hematoma or bilateral vocal cord paralysis were encountered. No significant difference was found between the type of admission (outpatient vs. inpatient) and postsurgical complications (p=0.24). The multivariable regression model retained significance for male gender and American Society of Anesthesiologists Classification III as potential predictors of postoperative complications. Healthcare costs would be reduced by at least 15.5% with the implementation of outpatient surgery. CONCLUSION: Outpatient thyroidectomy is as safe as inpatient thyroidectomy given the proper selection of cases. We project cost containment of over $711 thousand per 1,000 cases for outpatient thyroid surgeries.

The incidence of thyroid gland invasion in advanced laryngeal squamous cell carcinoma.

INTRODUCTION: Invasion of the thyroid gland is not a general feature of advanced laryngeal carcinoma. There is no need for performing thyroidectomy in all total laryngectomy cases. OBJECTIVES: To evaluate the frequency of the thyroid gland invasion in patients with advanced laryngeal squamous cell carcinoma submitted to total laryngectomy and thyroidectomy and to determine whether clinical and pathological characteristics of laryngeal carcinoma can predict glandular involvement. METHODS: A retrospective case series with chart review, from March 2009 to January 2018, was undertaken in the the Princess Norah Oncology Center, King Abdul-Aziz Medical City, Jeddah/KSA. An inception cohort of 56 patients with laryngeal squamous cell carcinoma was considered. Nine cases were excluded. All patients had advanced stage cancer of the larynx (clinically T3‒T4) and underwent total laryngectomy in association with thyroidectomy. Total thyroidectomy was performed in all bilateral lesions or if there was suspicion of contralateral lobe involvement. Hemithyroidectomy was performed in all lateralized lesions. Retrospective histopathologic analysis of thyroid specimens was subsequently performed. The frequency of thyroid gland invasion was calculated and analysis of demographic, clinical and pathological characteristics associated with thyroid gland invasion was performed. RESULTS: In all, 47 patients underwent total laryngectomy (40 treated with primary laryngectomy and seven treated with salvage laryngectomy following radiation failure or chemoradiation failure). Hemithyroidectomy was performed in 42 patients and the total thyroidectomy was performed in five patients. The overall frequency of invasion of the thyroid gland was 4.3%. Glandular involvement was seen in one advanced transglottic squamous cell carcinoma and one subglottic. In spite of thyroid cartilage invasion in 25.5% of cases detected in the preoperative radiological imaging, only one case demonstrated microscopic thyroid gland invasion. CONCLUSIONS: Thyroidectomy may only be required during total laryngectomy for selected cases of advanced transglottic tumors and tumors with subglottic extension more than 10 mm.

McGill Thyroid Nodule Score in Differentiating Thyroid Nodules in Total Thyroidectomy Cases of Indeterminate Nodules.

Fine-needle aspiration biopsy (FNAB) is the first-line modality in the evaluation of thyroid nodules. However, the results of indeterminate pathology place the thyroid surgeon in difficult management situations. This study evaluates McGill Thyroid Nodule Score (MTNS) to identify thyroid nodules that harbor malignancy in cases of indeterminate FNABs and to guide surgeon about the need and extent of surgery. We conducted a retrospective chart review of 344 patients who underwent total thyroidectomy between January 2013 and January 2018. Patients with FNAB of indeterminate nodules (Bethesda types III, IV, and V) and calculated MTNS were included in the study. Postoperative histopathology was divided into benign and malignant groups. The median and the mean MTNS, the malignancy rate, and the standard deviations were calculated for each subgroup. Of the 344 patient charts reviewed, 106 (30.8%) had an indeterminate FNA biopsy. Eighty-one (76.4%) patients were females and 25 (23.6%) were males. Final pathology revealed malignancy in 69 patients (65.1%). The mean MTNS of patients with malignant pathology (12.81  ± 3.55) was higher than the mean in the benign group (8.32  ± 2.32). 82.4% of thyroid nodules with median MTNS of less than 8 had a benign pathology, and 91.4% of thyroid nodules with median MTNS equal or more than 11 had a malignant pathology (p = 0.002). The rate of malignancy in our series of indeterminate FNABs was 65.1%. The MTNS can be of value to thyroid surgeons in preoperative decision-making when dealing with an indeterminate thyroid nodule.

Surgical Complications After Thyroid Surgery: A 10-Year Experience at Jeddah, Saudi Arabia.

To evaluate the incidence and predictive risk factors of complications in patients who underwent thyroid surgery at our hospital with a residency training program. This retrospective cohort study analyzed the complications in all patients who underwent thyroid surgery between January 2008 and December 2017. Demographic data, preoperative diagnosis based on fine needle aspiration cytology, surgical approach, permanent pathology, postoperative complications, and factors associated with complications were recorded. At our hospital, 456 patients underwent thyroidectomy. The most common surgical complications were asymptomatic biochemical hypocalcemia and symptomatic hypocalcemia in 109 (23.9%) and 50 (11%) patients, respectively. Other surgical complications included permanent hypocalcemia, transient vocal cord palsy, permanent vocal cord palsy, hematoma, seroma, chyle fistula, and Horner's syndrome. Mean age > 45 years and more extensive surgery were significantly associated with overall complications (P = 0.003; < 0.001). Mean age > 50 years and vitamin D level < 25 nmol/L (< 10 ng/mL) were significantly associated with hypocalcemia (P = 0.008; < 0.001). Moreover, the extent of surgery and advanced thyroid carcinoma were significantly associated with vocal cord palsy (P < 0.001; 0.05). Hypocalcemia and vocal cord palsy are the most significant complications. Thyroid surgery can be performed safely by senior residents in the residency training program under the direct supervision of an experienced surgeon.

Head and neck incidentalomas on positron emission tomographic scanning: ignore or investigate?

BACKGROUND AND OBJECTIVE: Incidental head and neck abnormalities are increasingly detected with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). Incidental thyroid lesions on PET are described in many studies; however, no reports have definitively identified incidental findings in multiple head and neck sites. The aim of this study was to (1) review the related literature, (2) identify the incidence and significance of head and neck incidentalomas on PET/computed tomography (CT) scanning, and (3) attempt to establish management recommendations for head and neck PET incidentalomas. STUDY DESIGN: Retrospective study. SETTING: Tertiary care centre. METHODS: Head and neck incidentaloma cases from whole-body 18F-FDG PET/CT scans were reviewed based on specific inclusion criteria from January 2009 to January 2010 at the Jewish General Hospital. The patients had been scanned for known or suspected malignant lesions in non-head and neck sites. Patients with incidental head and neck abnormalities were identified. RESULTS: The scans of 38 of 1565 (2.43%) subjects who underwent FDG-PET scanning for known or suspected cancer demonstrated head and neck incidentalomas. In 8 of 38 cases (21.05%), malignancies were discovered in the incidentaloma lesion (5 thyroid, 2 parotid, and 1 cervical lymph node), and all were new primary malignancies. Five of the 8 (62.5%) demonstrated significantly high standard uptake value (SUV). CONCLUSION: Head and neck PET/CT incidentalomas are quite common. A significantly high SUV strongly suggests the presence of malignancy. Head and neck incidentalomas merit consultation and further evaluation.

The role of sentinel lymph node biopsy in differentiated thyroid carcinoma.

OBJECTIVE: To determine whether sentinel lymph node (SLN) biopsy can accurately predict central compartment metastasis in patients with differentiated thyroid carcinoma. DESIGN: Prospective clinical study. SETTING: Academic tertiary care center. PATIENTS: Ninety-eight patients (82 women and 16 men; mean age, 48.3 years) underwent a total thyroidectomy and central compartment dissection. INTERVENTION: Peritumoral injection of methylene blue dye, 1%, followed by SLN biopsy. MAIN OUTCOME MEASURES: The final pathology report established the presence of metastasis among SLNs and lymph nodes that did not stain blue (non-SLNs [NSLNs]). RESULTS: Differentiated thyroid carcinoma was found in 75 of 98 patients (77%). Seventy of 75 patients with differentiated thyroid carcinoma presented with SLNs and/or NSLNs within the central compartment. Fifteen of 70 patients had metastasis-positive SLNs, while 55 had metastasis-negative SLNs. Six of 15 patients with positive SLNs also had positive NSLNs. No patients with negative SLNs were found to have positive NSLNs. Sentinal lymph node status was a highly significant predictor of NSLN result (Fisher exact test, P < .001). The accuracy, sensitivity, specificity, and positive and negative predictive values of SLN biopsy were 87%, 100%, 86%, 40%, and 100%, respectively. CONCLUSIONS: To our knowledge, this is the largest series of SLN biopsy in patients with differentiated thyroid carcinoma. Our experience suggests that this is an accurate and noninvasive means to identify subclinical lymph node metastasis. Because negative SLNs correlate strongly with a negative central compartment (100% in this study, P < .001), this technique can be used as an intraoperative guide when determining the extent of surgery necessary in cervical level VI.