갑상선암 수술 환자들이 원하는 교육은?

Background and Objectives: To prevent getting wrong information and improve high quality of life, it is necessary to provide accurate information and patient education. This study aimed to collect basic data and develop educational program for thyroid cancer patient by understanding their educational needs. Materials and Methods: Between April 16 and June 15, 2012, 159 patients who underwent thyroid cancer surgery were enrolled. This survey consisted of 5 areas including management of the symptom and the complication after surgery, postoperative wound and dietary management, treatment plan after discharge, medication management, and daily life. Results: The most common way for the patients to acquire information about the disease was Internet and the patients who used INTERNET as their information source were 54.7%. Doctors (76.1%) and nurses (21.4%) were the preferred educators for the patients, and small group education was the preferred education method. Specifically the need for "management of the symptom and the complication after surgery" was the highest (3.33), followed by "treatment plan after discharge" (3.31), "medication management" (3.19), "postoperative wound and dietary management" (3.17). Conclusion: Medical team including doctors and nurses should be the center to activate small group education for patients. Professional and individualized education program should be developed to give the proper education to patients and their family.ope

On-site ultrasound-guided localization for impalpable nodal recurrences in papillary thyroid carcinoma patients

Purpose The cervical lymph nodes are the most common sites of locoregional recurrence in patients with papillary thyroid carcinoma (PTC). Accurate tumor localization is important for the successful removal of impalpable recurrences in the cervical lymph nodes. We evaluated the benefits of ultrasound-guided localization (UGL) performed by a single surgeon on site. Methods Of 53 PTC patients who underwent reoperation for impalpable nodal recurrences, 32 (group 1) were assessed only using preoperative imaging, while 21 (group 2) were additionally evaluated by on-site UGL performed by the operating surgeon. Postoperative outcomes were compared between the two groups. Results Operation times were significantly shorter (P < 0.001) and the mean size of the resected lymph nodes were smaller (P = 0.013) for group 2 patients. More lymph nodes were identified and resected in group 1 (3.56 vs. 3.19), but the rate of positive lymph nodes was significantly higher in group 2 (P < 0.001). There were no differences between the two groups in terms of resection success rate, complication rate, and postoperative hospital stay. During a mean follow-up period of 27.6 months, 52 patients (98.1%) showed no evidence of recurrence on routine ultrasound, and serum thyroglobulin concentrations remained < 1 ng/mL in 49 patients (92.5%). Conclusion On-site UGL performed by the operating surgeon is useful for accurate resection of impalpable nodal recurrences in PTC patients.ope

Overcoming the limitations of fine needle aspiration biopsy: detection of lateral neck node metastasis in papillary thyroid carcinoma

PURPOSE: Ultrasound (US) and US-guided fine needle aspiration biopsies (FNAB) are considered the modalities of choice for assessing lymph nodes suspected of containing metastases, but the sensitivity of FNAB varies and is specific to the operator. We analyzed the risk of FNAB providing false negative results of lateral neck node metastasis, and evaluated diagnostic accuracy of FNAB, in patients with papillary thyroid cancer. MATERIALS AND METHODS: FNAB was performed in 242 patients suspected of having lateral neck node metastasis on preoperative imaging. Thyroglobulin in the fine-needle aspirate washout (FNA wash-out Tg) and computed tomography enhancement (Hounsfield units) were measured. Patients with negative results on FNAB were examined by intraoperative frozen section. The false negative and true negative groups were compared. RESULTS: Of the 242 patients, 130 were confirmed as having lateral neck node metastases. In 74 patients, the metastasis was identified by FNAB. False positive results were observed in 2 patients (0.8%) and false negatives in 58 (44.6%). Risk analysis showed that patient age 1 cm (p=0.008) and elevated FNA wash-out Tg (p=0.004) were significantly associated with false negative results on FNAB. The accuracy of FNAB increased significantly when combined with FNA wash-out Tg (p=0.003). CONCLUSION: To reduce the false negative rate of FNAB, patient age (1 cm) and FNA wash-out Tg (>34.8 ng/mL) should be considered in preoperative planning. Accuracy may be improved by combining the results of FNAB and FNA wash-out Tg.ope

Parathyroid score can predict the duration of required calcium supplementation after total thyroidectomy

BACKGROUND: Postoperative hypoparathyroidism is the most common complication after total thyroidectomy, owing to unintentional injury or decreased blood flow to the parathyroid glands. Prediction of postoperative hypoparathyroidism would be helpful for surgeons to manage postoperative hypocalcemia. In this study, we scored the discoloration of the parathyroid glands using a new parathyroid scoring system and evaluated the correlation between the parathyroid score and duration of required calcium supplementation after total thyroidectomy. METHODS: A total of 316 patients undergoing total thyroidectomy between November 2009 and April 2010 were enrolled in this retrospective study. Parathyroid scoring was performed by one experienced surgeon. The status of each of the 4 parathyroid glands was classified as normal color (3 points), slightly discolored (2 points), dark discoloration (1 point), or loss of the gland (0 points), resulting in possible total scores of 0-12. Serum parathyroid hormone (PTH), serum calcium, and ionized calcium concentrations were measured at 2 hours, 2 weeks, 3 months, 6 months, and 1 year after surgery. Patients were also divided into three groups based on the duration of required calcium supplementation: no required supplementation (n = 260, 82.3%), required supplementation for <6 months (n = 38, 12%), and required supplementation for ≥6 months (n = 18, 5.75%). RESULTS: Parathyroid scores were positively correlated with ionized PTH concentrations at 2 hours (r = 0.053, p < 0.001), 2 weeks (r = 0.056, p < 0.001), 3 months (r = 0.032, p<0.001), 6 months (r = 0.072, p < 0.001), and 1 year (r = 0.071, p < 0.001) after thyroidectomy. Parathyroid scores were significantly and inversely associated with the duration of required calcium supplementation (p = 0.001). CONCLUSIONS: Parathyroid scores at the end of surgery might be helpful for predicting the degree of postoperative hypocalcemia after total thyroidetomy.ope

The Clinical Significance of the Right Para-Oesophageal Lymph Nodes in Papillary Thyroid Cancer

PURPOSE: Although guidelines indicate that routine dissection of the central lymph nodes in patients with thyroid carcinoma should include the right para-oesophageal lymph nodes (RPELNs), located between the right recurrent laryngeal nerve and the cervical oesophagus and posterior to the former, RPELN dissection is often omitted due to high risk of injuries to the recurrent laryngeal nerve and the right inferior parathyroid gland. MATERIALS AND METHODS: We retrospectively identified all patients diagnosed with papillary thyroid carcinoma who underwent total thyroidectomy with central lymph node dissection, including the RPELNs, between January 1, 2009 and December 31, 2013 at the Thyroid Cancer Center of Yonsei University College of Medicine, Seoul, Korea. RESULTS: Of 5556 patients, 148 were positive for RPELN metastasis; of the latter, 91 had primary tumours greater than 1 cm (p<0.001). Extrathyroidal extension by the primary tumour (81.8%; p<0.001), bilaterality, and multifocality were more common in patients with than without RPELN metastasis; however, there were no significant differences in age and sex between groups. A total of 95.9% of patients with RPELN metastasis had central node (except right para-oesophageal lymph node) metastasis, and the incidence of lateral neck node metastasis was significantly higher in patients with than without RPELN metastasis (63.5% vs. 14.3%, p<0.001). Forty-one patients underwent mediastinal dissection, with 11 patients confirmed as having mediastinal lymph node metastasis with RPELN metastasis on pathological examination. CONCLUSION: RPELN metastasis is significantly associated with lateral neck and mediastinal lymph node metastasis.ope

Diagnostic Thyroidectomy May Be Preferable in Patients With Suspicious Ultrasonography Features After Cytopathology Diagnosis of AUS/FLUS in the Bethesda System

Atypia/follicular lesion of undetermined significance (AUS/FLUS) is a new category in the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) for which repeat fine-needle aspiration cytology (FNAC) is recommended. The aim of this study was to identify specific ultrasonography and clinical predictors of malignancy in a subset of thyroid nodules associated with cytology diagnoses of AUS/FLUS.Between January 2011 and December 2102, 5440 patients underwent thyroid surgery at our institution. Of these, 213 patients were diagnosed AUS/FLUS at the preoperative cytopathology diagnosis. The frequency of FNAC and ultrasonography images was compared between patients with cancerous and benign tumors based on their final pathology.Of the 213 patients, 158 (74.2%) were diagnosed with thyroid carcinoma in their final pathology reports. In univariate and multivariate analyses, the frequency of FNAC was not significantly correlated with the cancer diagnosis. Hypoechogenicity (odds ratio 2.521, P = 0.007) and microcalcification (odds ratio 3.247, P = 0.005) were statistically correlated with cancer risk.Although AUS/FLUS in cytopathology is recommended for repeating FNAC in BSRTC, we proposed that thyroid nodules with ultrasonography findings that suggest the possibility of cancer should undergo thyroidectomy with diagnostic intent.ope

Solitary lateral neck node metastasis in papillary thyroid carcinoma

BACKGROUND: Papillary thyroid carcinoma (PTC) is associated with a high incidence of regional node metastasis, but the patterns of lateral neck node metastasis (LNM) vary. Occasionally, a solitary LNM (SLNM) is seen in PTC patients. We therefore assessed whether selective single level node dissection is appropriate in PTC patients with SLNM. METHODS: We retrospectively reviewed the medical records of 241 PTC patients who underwent total thyroidectomy with central neck dissection plus ipsilateral internal jugular node dissection (level II to IV) between January 2010 and December 2011. Of these patients, 51 had SLNM and 190 had multiple LNM (MLNM). The clinicopathologic characteristics of the two groups were compared. RESULTS: Age, gender ratio, and numbers of lateral neck nodes harvested (29.4±11.0 versus 30.3±9.5; P=0.574) were similar in the SLNM and MLNM groups. Mean primary tumor size was significantly smaller in the SLNM than in the MNLM group (1.03 cm versus 1.35 cm; P=0.037). The proportion of patients with primary tumor≤1 cm was significantly greater in the SLNM group (60.8% versus 38.4%; P=0.006), whereas the proportion with maximal node size≤0.7 cm (28.9% versus 73.3%; P<0.001) and the proportion with capsular invasion (62.7% versus 83.7%, P=0.002) were significantly lower in the SLNM than in the MLNM group. CONCLUSIONS: Selective single level neck dissection can be considered as an alternative to systemic lateral neck dissection in PTC patients with SLNM, maximal metastatic node size≤0.7 cm, and no extrathyroidal invasion.ope

SoLAT (Sorafenib Lenvatinib alternating treatment): a new treatment protocol with altnernating Sorafenib and Lenvatinib for refractory thyroid cancer

BACKGROUND: In the last decade, several tyrosine kinase inhibitors (TKIs), which disrupt pathways involved in the proliferation and tumorigenesis of thyroid cancer, have been extensively studied. Two different TKIs, lenvatinib and sorafenib, were recently approved by both the US FDA and European Medicine Agency. Until date, the duration of the TKI response is not sufficient and resistance eventually occurs. The goal of this study was to investigate a new treatment protocol, SoLAT, using sorafenib and lenvatinib alternatively on refractory thyroid cancer. METHODS: Patient-derived aggressive papillary thyroid cancer (PTC) cell lines from patients with biochemical and histologically proven aggressive RAI-refractory papillary thyroid cancer were exposed to sorafenib and lenvatinib alternatively. Human thyroid cancer cell xenografts were obtained by injecting patient-derived aggressive PTC cell lines into the flank of female BALB/c nude mice. Tumor-bearing mice were treated with sorafenib and lenvatinib alternatively. Cell viability assay, immunofluorescence analysis, confocal imaging, immunoblot analysis, flow cytometry analysis of cell cycle and a tube formation assay were performed. RESULTS: SoLAT was more effective for advanced PTC cell lines than individual treatment. Immunoblot analysis showed that SoLAT markedly increased levels of cell cycle inhibitors (p53 and p21), and pro-apoptotic factors (Apaf-1 and cleaved caspase 3) and decreased levels of positive cell cycle regulators (cyclin D1, CDK4, CDK6) and anti-apoptotic factors (p-NFκB, Bcl-2). Increased sub-G0/G1 population was observed in the SoLAT group, leading to apoptosis, cell cycle arrest, and strong inhibition of advanced PTC cell viability. SoLAT reduced the level of EMT markers such as vimentin, E-cadherin, Snail and Zeb1 by FGFR inhibition. In the xenograft model, individual treatment with sorafenib or lenvatinib did not markedly suppress patient-derived aggressive PTC cell xenograft tumors, whereas SoLAT significantly suppressed the proliferation of these tumors. CONCLUSIONS: SoLAT was more effective than individual treatment with sorafenib or lenvatinib in inhibiting PTC progression by inducing cell cycle arrest. Studies using both in vitro cell culture and an in vivo xenograft model provided evidence of tumor shrinkage with SoLAT. We suggest that these effects may be due to reduced EMT-mediated drug resistance in the aggressive PTC modelope

Anti-cancer Effects of HNHA and Lenvatinib by the Suppression of EMT-Mediated Drug Resistance in Cancer Stem Cells

Anaplastic thyroid cancer (ATC) constitutes less than 2% of total thyroid cancers but accounts for 20-40% of thyroid cancer-related deaths. Cancer stem cell drug resistance represents a primary factor hindering treatment. This study aimed to develop targeted agents against thyroid malignancy, focusing on individual and synergistic effects of HNHA (histone deacetylase), lenvatinib (FGFR), and sorafenib (tyrosine kinase) inhibitors. Patients with biochemically and histologically proven papillary thyroid cancer (PTC) and ATC were included. Cell samples were obtained from patients at the Thyroid Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. PTC and ATC cells were treated with lenvatinib or sorafenib, alone or in combination with HNHA. Tumor-bearing mice (10/group) were administered 10 mg/kg lenvatinib (p.o.) or 40 mg/kg sorafenib (p.o.), alone or in combination with 25 mg/kg HNHA (i.p.) once every three days. Gene expression in patient-derived PTC and ATC cells was compared using a microarray approach. Cellular apoptosis and proliferation were examined by immunohistochemistry and MTT assays. Tumor volume and cell properties were examined in the mouse xenograft model. HNHA-lenvatinib combined treatment induced markers of cell cycle arrest and apoptosis and suppressed anti-apoptosis markers, epithelial-mesenchymal transition (EMT), and the FGFR signaling pathway. Combined treatment induced significant tumor shrinkage in the xenograft model. HNHA-lenvatinib combination treatment thus blocked the FGFR signaling pathway, which is important for EMT. Treatment with HNHA-lenvatinib combination was more effective than either agent alone or sorafenib-HNHA combination. These findings have implications for ATC treatment by preventing drug resistance in cancer stem cells.ope

Comparison between the Initial 25 Cases and the Last 25 Cases of Laparoscopic Colorectal Resection during a Learning Period and According to the Clinicopathologic Outcomes

Purpose: The present study was designed to investigate the clinicopathologic results of performing laparoscopic colorectal resection during a learning curve period. Methods: A prospective analysis of 50 consecutive patients who underwent elective laparoscopic colorectal surgery was conducted between April 2006 and September 2006. We monitored the learning curve of one surgeon. The perioperative clinical results, complications and pathologic details were evaluated prospectively. The 50 patients were divided into two chronological groups (the 25 early cases and the 25 late cases). Statistical analysis between the two groups was performed to evaluate the different outcomes and with taking into account the progressively increasing experience. Results: A total of 45 cases had colorectal cancer. The operative procedure was executed by the standard laparoscopic technique and according to the tumor location, with proper lymph node dissection. Curative resection was performed for the all malignant cases. The remaining 5 cases all involved benign disease. The overall complication and conversion rates were 12% and 6%, respectively. All the complications were treated conservatively. The pathologic outcomes for the malignant cases were acceptable, with no differences being manifested between the two groups. The complication rate and the length of stay were decreased in the late group. Conclusion: Laparoscopic colorectal resection can be performed safely and effectively. The clinicopathologic outcomes were acceptable even though the cases of the present study were done during the learning curve period of a surgeon.ope