Thyroid Hemiagenesis Associated with Hyperthyroidism

WOS: 000215209500081PubMed: 26185699Thyroid hemiagenesis (TH), very rare congenital anomaly, is generally asymptomatic. We report two cases of TH with hyperthyroidism. Case One. The patient presented with signs and symptoms of thyrotoxicosis. Physical examination revealed asymmetric nodular goitre at right lobe. Biochemical analysis revealed the diagnosis of hyperthyroidism. Ultrasound showed multinodular hypertrophy in the right lobe and absence of the left lobe. Nuclear scan, confirming absence of the left lobe, showed hot nodules in the right one. The diagnosis was toxic multinodular goitre. Case Two. The thyroid was not palpable in this patient presented with signs and symptoms of thyrotoxicosis. Biochemical analysis revealed the diagnosis of autoimmune thyrotoxicosis. Ultrasound showed mild diffuse hyperplasia of the right lobe and agenesis of the left lobe. Nuclear scan, confirming absence of the left lobe, showed increasing diffuse uptake of radiotracer in the right one. The diagnosis was Graves' disease in this patient. After antithyroid medication, the patients were surgically treated with total excision of the thyroid tissue. TH is sometimes associated with disorders of the thyroid. Hyperthyroidismmakes THcases symptomatic. During evaluation of patients, ultrasound and nuclear scan usually report agenesis of one lobe and establish the diagnosis of TH. The surgical treatment is total removal of hyperactive tissue and total excision of the remaining lobe

Intraoperative Monitoring of External Branch of the Superior Laryngeal Nerve: Functional Identification, Motor Integrity, and its Role on Vocal Cord Function

WOS: 000466370000010PubMed: 28952819Purpose: Beside recurrent laryngeal nerve (RLN), protection of the external branch of the superior laryngeal nerve (EBSLN) is required for complication-free thyroid surgery. This study investigates the contribution of intraoperative neuromonitoring (IONM) to identification and motor integrity of the EBSLN. Methods: This prospective study was performed on 245 EBSLNs in 147 patients with thyroid surgery. The rate of visual identification, contribution of IONM to functional localization, the rate and levels of recordable waveform amplitude from vocal cord (VC) movement were determined during surgery. Results: 164 (66.9%) EBSLNs were visually identified and additional 74 branches were functionally identified by IONM. Additional identification rate of IONM was 30.2%. Seven (2.9%) EBSLNs could not be identified during surgery. Cricothyroid muscle (CTM) twitch established functional integrity in 97.1% of EBSLNs. Electrophysiological stimulation of 151 (63.4%) EBSLNs created waveform amplitude >100 mu V that mean amplitude level was calculated as 186 mu V, and an amplitude >300 mu V was recorded in 19 of 151 (12.6%) EBSLNs. Conclusions: In addition to visual identification, surgeons can functionally localize the EBSLN with the assistance of IONM that CTM twitch is a reliable evience for functional integrity of the EBSLN. In the majority of patients, stimulation of the EBSLN creates recordable waveform amplitude thus the EBSLN appears to be a second source of motor innervations for intrinsic laryngeal muscles

Nonrecurrent Laryngeal Nerve: Precise Detection by Electrophysiological Nerve Monitoring

WOS: 000450940700109PubMed: 30042921Complication-free thyroid surgery is mainly based on the motor integrity of the recurrent laryngeal nerve (RLN). The nonrecurrent laryngeal nerve (non-RLN) is a rare anatomical variation that may increase the risk of vocal cord palsy. Early identification and exposure of the non-RLN may minimize injury risk. This case report presents functional detection of the nonRLN by intraoperative neuromonitoring (IONM). Total thyroidectomy was performed under the guidance of IONM on a patient with bulky multinodular goiter. The first step of IONM is pre-dissection stimulation (V1) of the right vagus nerve (VN). VI at a standard distal point was negative as indicated by the absence of both a sound signal and wave amplitude. The right VN was then followed proximally and dissected under the guidance of IONM. This dissection established a proximal point creating a positive signal that led us to determine the separation point of the non-RLN. The right non-RLN arising from the proximal VN was identified and fully exposed until laryngeal entry. Its motor integrity was confirmed with post-dissection signals. The left RLN was identified at the usual anatomical position that was fully exposed and preserved during thyroid surgery. Total thyroidectomy was then accomplished without complication. The postoperative period was uneventful. Postoperative laryngoscopy confirmed normal vocal cord function. The non-RLN is accurately identified by IONM during the early part of the thyroid surgery. The absence of a distal VN signal is predictive of the non-RLN. IONM-guided proximal dissection of the right VN leads to the identification of the non-RLN. The prediction of the non-RLN by the absence of a VN signal during an early stage of surgery may prevent or minimize the risk of nerve injury

Visual and electrophysiological identification of the external branch of superior laryngeal nerve in redo thyroid surgery compared with primary thyroid surgery

WOS: 000469783100001PubMed: 31183330Purpose: Thyroid reoperations are surgically challenging because of significant anatomical variance. Visual and functional identification of the external branch of the superior laryngeal nerve (EBSLN) were studied in 2 groups of patients who underwent primary and redo thyroid surgery. Methods: This study was conducted on 200 patients: 100 patients with redo and 100 patients with primary thyroid surgery. In addition to visual identification, nerve branches were functionally identified by intraoperative nerve monitoring (IONM). Visual, functional, and total identification rates of the EBSLN in both primary and redo surgery were determined and compared between the 2 groups. Results: We attempted to identify 138 and 170 EBSLNs at risk in redo and primary surgery, respectively. Visual identification rates were 65.3% and 30.4% (P < 0.001) in primary and redo surgery groups, respectively. In total, 164 (96.5%) and 97 EBSLNs (70.3%) were identified in primary and redo surgery, respectively (P < 0.001), including the use of IONM. In primary surgery group, 53 nonvisualized EBSLNs of 164 identified nerves (32.3%) were determined by IONM alone. In redo surgery group, 55 of 97 identified nerves (56.7%) were determined by IONM alone (P < 0.001). Conclusion: Both visual and total identification rates of the EBSLN are significantly decreased in reoperative thyroidectomy. IONM increases the total identification rate of the EBSLN in primary and redo thyroid surgery. Electrophysiological monitoring makes a substantial contribution to the identification of the EBSLN both in primary and especially in redo thyroid surgery

Clinical importance of discordance of hormone receptors and Her2/neu status after neoadjuvant chemotherapy in breast cancer

WOS: 000347742000004PubMed ID: 25536590Purpose: The aim of this study was to compare the hormone receptors' (HR) and HER2/neu status between core needle biopsy (CNB) and residual tumor after surgery of breast cancer treated with neoadjuvant chemotherapy (NAC), and also to evaluate the impact of discordance and other clinicopathological factors on survival. Methods: Oestrogen receptor (ER), progesterone receptor (PR) and HER2/neu status were evaluated by immunohistochemistry (IHC) on 90 CNBs of primary tumors and surgical specimens after NAC (study group); 53 patients without NAC served as control group, and discordance was compared between the two groups. The association between discordance of HR status after NAC and various other clinicopathological factors was tested with Spearman's test. Results: Pathological complete response (PCR) was achieved in 10 (11.1%) patients after NAC. ER and PR changed significantly more in the study than in the control group. ER and PR discordance was detected in 10 (12.5%) and 17 (21.2%) patients in the NAC group and in 1 (1.8%) and 2 (3.7%) patients in the control group (p=0.04 and p=0.005, respectively). ER discordance was related with HER2/neu change. Furthermore, PR discordance correlated with CNB, ER and treatment response, while HER2/neu discordance was associated with treatment response (p=0.05). ER discordance was found to be an independent prognostic factor for progression-free survival (PFS) (p=0.02). Conclusion: NAC might cause alterations in ER, PR or HER2/neu status in breast cancer, and they should be re-tested in the residual tumor after NAC to optimize adjuvant therapy

In Which Luminal Breast Cancers Might NeoadjuvantChemotherapy Be Appropriate to Achieve a PathologicalComplete Response in Axillary Lymph Nodes?

Objectives: In this study, we aimed to evaluate in which luminal/human epidermal growth factor receptor 2 negative(her2-) breast cancers (BCs) would be achieved complete pathological response in axillary lymph nodes with neoadjuvantchemotherapy (ypN0).Methods: We retrospectively analyzed 66 patients with luminal/her2- BC who were operated after neoadjuvant chemotherapy(NAC). We evaluated the predictive factors for ypN0 after NAC.Results: We detected ypT0 in 15.2% of the patients and ypN0 in 31.8%. Univariate analysis indicated that grade, cNstage, and anatomical stage were significant predictors of ypN0. According to the multivariate analysis, grade was theonly significant factor in predicting ypN0 independently of other factors (p=0.037). Considering the grades of cN1 patients,the ypN0 rate was 2/18 (11.1%) for grade 1-2 and 7/10 (70%) for grade 3 (p=0.01).Conclusion: In the presence of cN1 axillary lymph nodes, the decision of NAC can be challenging for clinicians in luminalBC patients, especially with no clear indication for NAC. Nowadays, if ycN0 is provided after NAC in cN1 cases, methodssuch as sentinel lymph node dissection/targeted axillary dissection are more commonly used for axillary staging.Based on the findings of our study, we think it would be appropriate to use NAC in patients with luminal BC with thegoal of reducing axillary surgery in the presence of cN1, grade 3 tumors

Clinical importance of discordance in hormone receptor and HER2/NEU status after neoadjuvant chemotherapy in breast cancer

Aim: Neoadjuvant chemotherapy (NAC) is used longer for both locally advanced breast cancer and early stage to increase breast conservation. Discordance of the hormone receptor (HR) status was reported to be 8-33% of the breast cancer after NAC. The aim of this study was to compare the HR and HER2/neu status between core needle biopsy (CNB) and residual tumour after surgery of breast cancer treated with NAC and also to evaluate effect of discordance and other clinicopathological factors on survival