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Squamous Differentiation in Papillary Thyroid Carcinoma: a Rare Feature of Aggressive Disease
e98
Scientific Poster Presentations: 2016 Clinical Congress
J Am Coll Surg
Tulane University School of Medicine, New Orleans, LA, American Hospital of Paris, Paris, France
compared based on clinical pathological characteristics and surgical outcome.
INTRODUCTION: The robot-assisted approach for thyroid and parathyroid surgery has been of increased interest recently in Asia, the United Stated, and Europe. However, few studies with small sample size reported the safety of this approach in parathyroid surgery. The aim of this study is to assess the safety and feasibility of robot-assisted parathyroid surgery in patients with primary hyperparathyroidism (PHPT).
RESULTS: Thirty-three patients underwent TA approach and 40 had RA approach. 69.7% of TA and 45.71% of RA were done on outpatient basis, and there was no significant difference in operative time or intra-operative blood loss. No reported cases of conversion to open using either approach. There was no statistically significant difference in the overall complication rate. In RA, there were 2 (5.71%) cases of hematoma, 1 required exploration, and 3 (8.57%) cases of seroma, compared to none in the TA. Only 1 patient in the TA had transient vocal cord paralysis and 2 in the RA; however, no permanent paralysis was reported. In comparison to the open approach, there was no difference in complication rate (OR¼6.01,95% CI 2.10-17.22), however; the operative time was significantly less in the control group (OR¼0.01,95% CI 0.01-0.06).
METHODS: Retrospective review of all patients with PHPT who underwent robot-assisted parathyroidectomy, in 2 centers over 5 years. We assessed demographic data and operative outcome measures including operative time, estimated blood loss, and associated complications. RESULTS: A total of thirty-seven procedures were performed, with preoperatively localized adenomas. The mean age was 55.110 and BMI was 25.985.89 with a female to male ratio of 4.3:1. Transaxillary approach was used in 91.9% and the remaining patients underwent retroauricular approach, with no reported cases of conversion to open. The mean operative time was 132 32.5 min. All patients had curative surgery, proven by drop of intraoperative parathyroid hormone level to normal range, which was maintained on follow-up visits. Only 2 minor complications were reported; 1 patient developed seroma and 1 had superficial wound infection. CONCLUSIONS: To our knowledge, this is the largest reported series on robot-assisted parathyroid surgery. This technique using either the transaxillary or retroauricular approaches is safe and feasible in selected patients with localized preoperative scans. It can be considered as an alternative for conventional open approach, especially in patients with concerns of a visible neck scar. Robot-Assisted Thyroidectomy: Analysis of Two Different Approaches Daniah Bu Ali, MD, Fadi Murad, MD, Patrick Aidan, MD, Zaid Al-Qurayshi, MD, MPH, Moha H Alshehri, MD, Taha A Hassoon, MD, Sang-Wook Kang, Emad Kandil, MBBCh, FACS Tulane University School of Medicine, New Orleans, LA INTRODUCTION: Several approaches have been described for robotic thyroid surgery. However, comparative studies have never been performed. The aim of this study is to compare the surgical outcome of transaxillary (TA) and retroauricular (RA) approaches in a single North American institution. METHODS: Retrospective review of 73 patients scheduled for robot-assisted thyroid and parathyroid surgery over 3 years by 1 surgeon. Patients were divided into 2 groups; TA and RA approaches, and those were compared to 177 control matched groups who underwent a traditional conventional cervical approach. Patients were
CONCLUSIONS: Retroauricular and transaxillary approaches for robot-assisted thyroid surgery are both safe and feasible with no additional complications risk compared to the open approach. Squamous Differentiation in Papillary Thyroid Carcinoma: a Rare Feature of Aggressive Disease Toni M Beninato, MD, Wouter P Kluijfhout, Frederick T Drake, MD, MPH, Elham Khanafshar, MD, Jessica E Gosnell, MD, FACS, Wen T Shen, MD, FACS, Quan-Yang Duh, MD, FACS, Insoo Suh, MD, FACS University of California-San Francisco, San Francisco, CA INTRODUCTION: Squamous differentiation in papillary thyroid carcinoma (PTC-SD) is a poorly understood pathological finding of unknown clinical significance. Selected case reports have suggested that PTC-SD is an aggressive tumor with a poor prognosis. Here we present the largest case series of PTC-SD reported in the United States. METHODS: The cancer registry at our tertiary care referral center was reviewed to identify all patients from 1995-2015 who had been diagnosed with PTC-SD on initial total thyroidectomy or lymph node dissection. All cases were reviewed by an endocrine pathologist to confirm the diagnosis. Patient demographic, pathology, and outcomes data were collected and reviewed. RESULTS: During the study period, 10 patients were diagnosed with PTC-SD, 6 in the primary tumor at the time of initial surgery, and 4 in lymph node metastases during surgery for recurrent disease. The median age at diagnosis was 56 years and half of the patients were male. Aggressive features such as multifocality (67%), extrathyroidal extension (67%), positive margin (89%), lymph node metastases (80%), and extranodal extension (60%) were far more prominent than is typically seen in classic PTC. Long-term follow-up (median 72 months) demonstrated high rates of locoregional recurrence (60%), pulmonary metastases (30%), and mortality (10%). CONCLUSIONS: Squamous differentiation is a rare finding in PTC that is associated with aggressive pathological features and
Vol. 223, No. 4S2, October 2016
poor long-term outcomes. This phenomenon may represent a step in progression toward dedifferentiation; thus, PTC-SD may warrant more vigilant surveillance and aggressive treatment than for classic PTC. Surgical Outcomes of Robot-Assisted Thyroidectomy for Thyroid Cancer: A 103 Cases Analysis from the United States and France Patrick Aidan, MD, Daniah Bu Ali, MD, Fadi Murad, MD, Moha H Alshehri, MD, Salem I Noureldine, MD, Taha A Hassoon, MD, Sang-Wook Kang, Emad Kandil, MBBCh, FACS Tulane University School of Medicine, New Orleans, LA, American Hospital of Paris, Paris, France INTRODUCTION: Recently, many studies reported the safety and feasibility of robot-assisted thyroidectomy, but most of these studies were performed in South Korea. Although there were several small series and case reports from the US, most of these cases were for benign disease. The aim of our study is to report the safety and feasibility of robot-assisted thyroidectomy for thyroid cancer in the Western population. METHODS: Retrospective review of all patients who underwent robot-assisted thyroidectomy over the last 5 years for thyroid cancer, in 2 centers, 1 in France and 1 in the US. We analyzed demographic data, operative outcome, and early oncologic outcome measures including pathological margins, biochemical (thyroglobulin level), and radiological evidence for recurrence. RESULTS: A total of 103 robotic cases were included; 29.12% underwent central lymph node dissection and 8.73% had lateral neck dissection. The transaxillary approach was performed in 93.2% and the remaining underwent retroauricular approach. The mean age was 45.5810.22 years and BMI was 26.326.53. The average nodule size was 2.331.34cm. The mean operative time was 160.3350.35 minutes with 3 patients required conversion to conventional cervical approach. Complications were reported in 6 (5.8%) patients including 1 hematoma, 2 seroma, and 3 patients developed transient vocal cord paralysis. All margins were negative, and there was no radiological or biological evidence of recurrence, except 2 (1.94%) patients developed recurrence 24 and 16 months after initial surgery. CONCLUSIONS: Robot-assisted thyroid surgery is a safe and feasible approach for thyroid cancer in the Western population, and is associated with sound oncologic outcome. Further future studies are warranted. Role of Surgeon-Performed Office and Pre-Incision Ultrasounds in the Management of Patients with Primary Hyperparathyroidism Aida Taye, MD, Erin R Bresnahan, Anusha Jayaram, William B Inabnet, MD, Randall P Owen, MD, FACS, Gustavo Fernandez-Ranvier, MD, PhD Mount Sinai Hospital, New York, NY
Scientific Poster Presentations: 2016 Clinical Congress
e99
INTRODUCTION: The management of primary hyperparathyroidism (PHPT) requires astute and cost-effective evaluation of imaging modalities prior to parathyroidectomy. We aimed to analyze the utility of surgeon-performed office neck ultrasound (OU) and pre-incision neck ultrasound (PIU) in treating PHPT. METHODS: This is a retrospective study of OU and PIU performed by 2 surgeons on 356 consecutive patients with PHPT at a single institution from 2013-2015. The accuracy of OU and PIU was established by comparing imaging results with surgical pathology, in cases with decline of intraoperative parathyroid hormone levels by 50% and in normal range after excising a single adenoma (SA), double adenomas (DA), or >2 glands. RESULTS: In this investigation, 288 (80.9%) patients with SA, 53 (14.9%) with DA, and 15 (4.2%) with >2 diseased glands were studied. For SA, sensitivity and specificity of OU to correctly lateralize the adenoma were 65.0% and 90.4%, respectively. However, when PIU was performed on the operating table, the sensitivity and specificity to detect the correct side increased to 89.0% and 94.5% respectively. The accuracy of PIU (90.9%) in correctly lateralizing SA was comparable to sestamibi (82.8%) and computed tomography (87.9%). For identifying presence of DA, negative predictive values were 83.6% for OU and 90.4% for PIU, whereas positive predictive values were 42.9% and 73.9%, respectively. In the 15 cases with >2 diseased glands, ultrasound was not able to localize all the adenomas. CONCLUSIONS: Surgeon-performed OU and PIU is a valuable tool in guiding focused parathyroidectomies in SA but is limited for multiple glands. Vanishing Thyroid Tumors: What Are They, and What Do They Mean for Patients? Lauren N Pontius, Linda M Youngwirth, MD, Samantha M Thomas, Randall P Scheri, MD, Sanziana A Roman, MD, Julie A Sosa, MD, FACS Duke University, Durham, NC INTRODUCTION: Vanishing thyroid tumors are rare tumors diagnosed with FNA cytology that cannot be confirmed on histology after thyroidectomy. Our aim was to examine factors associated with vanishing papillary thyroid cancer and patient outcomes. METHODS: The National Cancer Data Base (1998-2012) was queried for all patients with a clinical diagnosis of papillary thyroid cancer undergoing thyroidectomy with no tumor on final pathology (T0). Patients were compared with a second group with a clinical diagnosis of papillary microcarcinoma (PTMC) undergoing thyroidectomy with pathologic confirmation (pT1a). Demographic, clinical, and pathologic features were evaluated for all patients and compared between groups. RESULTS: In total, 183 patients met inclusion criteria. Patients with vanishing tumors (median size 1.0 cm) were more likely to be male (25.0% vs 17.0% PTMC, p ¼ 0.007), have regional
Scientific Poster Presentations: 2016 Clinical Congress
J Am Coll Surg
Tulane University School of Medicine, New Orleans, LA, American Hospital of Paris, Paris, France
compared based on clinical pathological characteristics and surgical outcome.
INTRODUCTION: The robot-assisted approach for thyroid and parathyroid surgery has been of increased interest recently in Asia, the United Stated, and Europe. However, few studies with small sample size reported the safety of this approach in parathyroid surgery. The aim of this study is to assess the safety and feasibility of robot-assisted parathyroid surgery in patients with primary hyperparathyroidism (PHPT).
RESULTS: Thirty-three patients underwent TA approach and 40 had RA approach. 69.7% of TA and 45.71% of RA were done on outpatient basis, and there was no significant difference in operative time or intra-operative blood loss. No reported cases of conversion to open using either approach. There was no statistically significant difference in the overall complication rate. In RA, there were 2 (5.71%) cases of hematoma, 1 required exploration, and 3 (8.57%) cases of seroma, compared to none in the TA. Only 1 patient in the TA had transient vocal cord paralysis and 2 in the RA; however, no permanent paralysis was reported. In comparison to the open approach, there was no difference in complication rate (OR¼6.01,95% CI 2.10-17.22), however; the operative time was significantly less in the control group (OR¼0.01,95% CI 0.01-0.06).
METHODS: Retrospective review of all patients with PHPT who underwent robot-assisted parathyroidectomy, in 2 centers over 5 years. We assessed demographic data and operative outcome measures including operative time, estimated blood loss, and associated complications. RESULTS: A total of thirty-seven procedures were performed, with preoperatively localized adenomas. The mean age was 55.110 and BMI was 25.985.89 with a female to male ratio of 4.3:1. Transaxillary approach was used in 91.9% and the remaining patients underwent retroauricular approach, with no reported cases of conversion to open. The mean operative time was 132 32.5 min. All patients had curative surgery, proven by drop of intraoperative parathyroid hormone level to normal range, which was maintained on follow-up visits. Only 2 minor complications were reported; 1 patient developed seroma and 1 had superficial wound infection. CONCLUSIONS: To our knowledge, this is the largest reported series on robot-assisted parathyroid surgery. This technique using either the transaxillary or retroauricular approaches is safe and feasible in selected patients with localized preoperative scans. It can be considered as an alternative for conventional open approach, especially in patients with concerns of a visible neck scar. Robot-Assisted Thyroidectomy: Analysis of Two Different Approaches Daniah Bu Ali, MD, Fadi Murad, MD, Patrick Aidan, MD, Zaid Al-Qurayshi, MD, MPH, Moha H Alshehri, MD, Taha A Hassoon, MD, Sang-Wook Kang, Emad Kandil, MBBCh, FACS Tulane University School of Medicine, New Orleans, LA INTRODUCTION: Several approaches have been described for robotic thyroid surgery. However, comparative studies have never been performed. The aim of this study is to compare the surgical outcome of transaxillary (TA) and retroauricular (RA) approaches in a single North American institution. METHODS: Retrospective review of 73 patients scheduled for robot-assisted thyroid and parathyroid surgery over 3 years by 1 surgeon. Patients were divided into 2 groups; TA and RA approaches, and those were compared to 177 control matched groups who underwent a traditional conventional cervical approach. Patients were
CONCLUSIONS: Retroauricular and transaxillary approaches for robot-assisted thyroid surgery are both safe and feasible with no additional complications risk compared to the open approach. Squamous Differentiation in Papillary Thyroid Carcinoma: a Rare Feature of Aggressive Disease Toni M Beninato, MD, Wouter P Kluijfhout, Frederick T Drake, MD, MPH, Elham Khanafshar, MD, Jessica E Gosnell, MD, FACS, Wen T Shen, MD, FACS, Quan-Yang Duh, MD, FACS, Insoo Suh, MD, FACS University of California-San Francisco, San Francisco, CA INTRODUCTION: Squamous differentiation in papillary thyroid carcinoma (PTC-SD) is a poorly understood pathological finding of unknown clinical significance. Selected case reports have suggested that PTC-SD is an aggressive tumor with a poor prognosis. Here we present the largest case series of PTC-SD reported in the United States. METHODS: The cancer registry at our tertiary care referral center was reviewed to identify all patients from 1995-2015 who had been diagnosed with PTC-SD on initial total thyroidectomy or lymph node dissection. All cases were reviewed by an endocrine pathologist to confirm the diagnosis. Patient demographic, pathology, and outcomes data were collected and reviewed. RESULTS: During the study period, 10 patients were diagnosed with PTC-SD, 6 in the primary tumor at the time of initial surgery, and 4 in lymph node metastases during surgery for recurrent disease. The median age at diagnosis was 56 years and half of the patients were male. Aggressive features such as multifocality (67%), extrathyroidal extension (67%), positive margin (89%), lymph node metastases (80%), and extranodal extension (60%) were far more prominent than is typically seen in classic PTC. Long-term follow-up (median 72 months) demonstrated high rates of locoregional recurrence (60%), pulmonary metastases (30%), and mortality (10%). CONCLUSIONS: Squamous differentiation is a rare finding in PTC that is associated with aggressive pathological features and
Vol. 223, No. 4S2, October 2016
poor long-term outcomes. This phenomenon may represent a step in progression toward dedifferentiation; thus, PTC-SD may warrant more vigilant surveillance and aggressive treatment than for classic PTC. Surgical Outcomes of Robot-Assisted Thyroidectomy for Thyroid Cancer: A 103 Cases Analysis from the United States and France Patrick Aidan, MD, Daniah Bu Ali, MD, Fadi Murad, MD, Moha H Alshehri, MD, Salem I Noureldine, MD, Taha A Hassoon, MD, Sang-Wook Kang, Emad Kandil, MBBCh, FACS Tulane University School of Medicine, New Orleans, LA, American Hospital of Paris, Paris, France INTRODUCTION: Recently, many studies reported the safety and feasibility of robot-assisted thyroidectomy, but most of these studies were performed in South Korea. Although there were several small series and case reports from the US, most of these cases were for benign disease. The aim of our study is to report the safety and feasibility of robot-assisted thyroidectomy for thyroid cancer in the Western population. METHODS: Retrospective review of all patients who underwent robot-assisted thyroidectomy over the last 5 years for thyroid cancer, in 2 centers, 1 in France and 1 in the US. We analyzed demographic data, operative outcome, and early oncologic outcome measures including pathological margins, biochemical (thyroglobulin level), and radiological evidence for recurrence. RESULTS: A total of 103 robotic cases were included; 29.12% underwent central lymph node dissection and 8.73% had lateral neck dissection. The transaxillary approach was performed in 93.2% and the remaining underwent retroauricular approach. The mean age was 45.5810.22 years and BMI was 26.326.53. The average nodule size was 2.331.34cm. The mean operative time was 160.3350.35 minutes with 3 patients required conversion to conventional cervical approach. Complications were reported in 6 (5.8%) patients including 1 hematoma, 2 seroma, and 3 patients developed transient vocal cord paralysis. All margins were negative, and there was no radiological or biological evidence of recurrence, except 2 (1.94%) patients developed recurrence 24 and 16 months after initial surgery. CONCLUSIONS: Robot-assisted thyroid surgery is a safe and feasible approach for thyroid cancer in the Western population, and is associated with sound oncologic outcome. Further future studies are warranted. Role of Surgeon-Performed Office and Pre-Incision Ultrasounds in the Management of Patients with Primary Hyperparathyroidism Aida Taye, MD, Erin R Bresnahan, Anusha Jayaram, William B Inabnet, MD, Randall P Owen, MD, FACS, Gustavo Fernandez-Ranvier, MD, PhD Mount Sinai Hospital, New York, NY
Scientific Poster Presentations: 2016 Clinical Congress
e99
INTRODUCTION: The management of primary hyperparathyroidism (PHPT) requires astute and cost-effective evaluation of imaging modalities prior to parathyroidectomy. We aimed to analyze the utility of surgeon-performed office neck ultrasound (OU) and pre-incision neck ultrasound (PIU) in treating PHPT. METHODS: This is a retrospective study of OU and PIU performed by 2 surgeons on 356 consecutive patients with PHPT at a single institution from 2013-2015. The accuracy of OU and PIU was established by comparing imaging results with surgical pathology, in cases with decline of intraoperative parathyroid hormone levels by 50% and in normal range after excising a single adenoma (SA), double adenomas (DA), or >2 glands. RESULTS: In this investigation, 288 (80.9%) patients with SA, 53 (14.9%) with DA, and 15 (4.2%) with >2 diseased glands were studied. For SA, sensitivity and specificity of OU to correctly lateralize the adenoma were 65.0% and 90.4%, respectively. However, when PIU was performed on the operating table, the sensitivity and specificity to detect the correct side increased to 89.0% and 94.5% respectively. The accuracy of PIU (90.9%) in correctly lateralizing SA was comparable to sestamibi (82.8%) and computed tomography (87.9%). For identifying presence of DA, negative predictive values were 83.6% for OU and 90.4% for PIU, whereas positive predictive values were 42.9% and 73.9%, respectively. In the 15 cases with >2 diseased glands, ultrasound was not able to localize all the adenomas. CONCLUSIONS: Surgeon-performed OU and PIU is a valuable tool in guiding focused parathyroidectomies in SA but is limited for multiple glands. Vanishing Thyroid Tumors: What Are They, and What Do They Mean for Patients? Lauren N Pontius, Linda M Youngwirth, MD, Samantha M Thomas, Randall P Scheri, MD, Sanziana A Roman, MD, Julie A Sosa, MD, FACS Duke University, Durham, NC INTRODUCTION: Vanishing thyroid tumors are rare tumors diagnosed with FNA cytology that cannot be confirmed on histology after thyroidectomy. Our aim was to examine factors associated with vanishing papillary thyroid cancer and patient outcomes. METHODS: The National Cancer Data Base (1998-2012) was queried for all patients with a clinical diagnosis of papillary thyroid cancer undergoing thyroidectomy with no tumor on final pathology (T0). Patients were compared with a second group with a clinical diagnosis of papillary microcarcinoma (PTMC) undergoing thyroidectomy with pathologic confirmation (pT1a). Demographic, clinical, and pathologic features were evaluated for all patients and compared between groups. RESULTS: In total, 183 patients met inclusion criteria. Patients with vanishing tumors (median size 1.0 cm) were more likely to be male (25.0% vs 17.0% PTMC, p ¼ 0.007), have regional