Educational Review: Intraoperative Parathyroid Fluorescence Detection Technology in Thyroid and Parathyroid Surgery

Background: Accurate parathyroid gland (PG) identification is a critical yet challenging component of cervical endocrine procedures. PGs possess strong near-infrared autofluorescence (NIRAF) compared with other tissues in the neck. This property has been harnessed by image- and probe-based near-infrared fluorescence detection systems, which have gained increasing popularity in clinical use for their ability to accurately aid in PG identification in a rapid, noninvasive, and cost-effective manner. All NIRAF technologies, however, cannot differentiate viable from devascularized PGs without the use of contrast enhancement. Here, we aim to provide an overview of the rapid evolution of these technologies and update the surgery community on the most recent advancements in the field. Methods: A PubMed literature review was performed using the key terms "parathyroid," "near-infrared," and "fluorescence." Recommendations regarding the use of these technologies in clinical practice were developed on the basis of the reviewed literature and in conjunction with expert surgeons' opinions. Results: The use of near-infrared fluorescence detection can be broadly categorized as (1) using parathyroid NIRAF to identify both healthy and diseased PGs, and (2) using contrast-enhanced (i.e., indocyanine green) near-infrared fluorescence to evaluate PG perfusion and viability. Each of these approaches possess unique advantages and disadvantages, and clinical trials are ongoing to better define their utility. Conclusions: Near-infrared fluorescence detection offers the opportunity to improve our collective ability to identify and preserve PGs intraoperatively. While additional work is needed to propel this technology further, we hope this review will be valuable to the practicing surgeon.</p

Patient Perspectives on the Extent of Surgery and Radioactive Iodine Treatment for Low-Risk Differentiated Thyroid Cancer

ObjectiveTo understand patient perspective regarding recommended changes in the 2015 American Thyroid Association (ATA) guidelines. Specifically, in regard to active surveillance (AS) of some small differentiated thyroid cancer (DTC), performance of less extensive surgery for low-risk DTC, and more selective administration of radioactive iodine (RAI).MethodsAn online survey was disseminated to thyroid cancer patient advocacy organizations and members of the ATA to distribute to the patients. Data were collected on demographic and treatment information, and patient experience with DTC. Patients were asked "what if" scenarios on core topics, including AS, extent of surgery, and indications for RAI.ResultsSurvey responses were analyzed from 1546 patients with DTC: 1478 (96%) had a total thyroidectomy, and 1167 (76%) underwent RAI. If there was no change in the overall cancer outcome, 606 (39%) of respondents would have considered lobectomy over total thyroidectomy, 536 (35%) would have opted for AS, and 638 (41%) would have chosen to forego RAI. Moreover, (774/1217) 64% of respondents wanted more time with their clinicians when making decisions about the extent of surgery. A total of 621/1167 of patients experienced significant side effects with RAI, and 351/1167 of patients felt that the risks of treatment were not well explained. 1237/1546 (80%) of patients felt that AS would not be overly burdensome, and quality of life was the main reason cited for choosing AS.ConclusionPatient perspective regarding choice in the management of low-risk DTC varies widely, and a large proportion of DTC patients would change aspects of their care if oncologic outcomes were equivalent

Neutrophil-lymphocyte and platelet-lymphocyte ratio as predictors of disease specific survival after resection of adrenocortical carcinoma

Background: The systemic inflammatory response may be associated with tumor progression. We sought to analyze the impact of neutrophillymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) on recurrence-free survival (RFS) and disease-specific survival (DSS) among patients who underwent surgery for adrenocortical carcinoma (ACC). Methods: Patients undergoing surgery for ACC were identified from a multi-center database. Cut-off values of 5 and 190 were defined as elevated NLR and PLR, respectively, and long-term outcome was assessed. Results: Among 84 patients with ACC, 29 (34.%) had NLR&gt;5 while 32 (40.5%) had PLR&gt;190. NLR and PLR were associated with larger tumors (NLR&gt;5: 5 cm, 0% vs. &gt;5 cm, 39.7%; PLR&gt;190: 5cm, 0% vs. &gt;5 cm, 45.7%), as well as need to resect of other organs (NLR&gt;5: other organ resected 48.8% vs. not resected 20.9%; PLR&gt;190: other organ resected 25.0% vs. not resected 56.4%)(all P&lt;0.05). Five-year RFS was associated with an elevated NLR (NLR5, 14.2% vs. NLR&gt;5, 10.5%) and PLR (PLR190: 19.4% vs. PLR&gt;190: 5.2%) (both P&lt;0.05). On multivariate survival analyses, PLR remained a predictor of RFS (HR 1.72), while NLR was associated with both DSS (HR 2.21) and RFS (HR 1.99) (both P&lt;0.05). Conclusions: Immune markers such as NLR and PLR may be useful to stratify patients with regards to prognosis following surgery for ACC

Neutrophil-lymphocyte and platelet-lymphocyte ratio as predictors of disease specific survival after resection of adrenocortical carcinoma.

BackgroundThe systemic inflammatory response may be associated with tumor progression. We sought to analyze the impact of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) on recurrence-free survival (RFS) and disease-specific survival (DSS) among patients who underwent surgery for adrenocortical carcinoma (ACC).MethodsPatients undergoing surgery for ACC were identified from a multi-center database. Cut-off values of 5 and 190 were defined as elevated NLR and PLR, respectively, and long-term outcome was assessed.ResultsAmong 84 patients with ACC, 29 (34.%) had NLR &gt; 5 while 32 (40.5%) had PLR &gt; 190. NLR and PLR were associated with larger tumors (NLR &gt; 5: ≤ 5 cm, 0% vs. &gt;5 cm, 39.7%; PLR &gt; 190: ≤ 5cm, 0% vs. &gt;5 cm, 45.7%), as well as need to resect of other organs (NLR &gt; 5: other organ resected 48.8% vs. not resected 20.9%; PLR &gt; 190: other organ resected 25.0% vs. not resected 56.4%)(all P &lt; 0.05). Five-year RFS was associated with an elevated NLR (NLR ≤ 5, 14.2% vs. NLR&gt; 5, 10.5%) and PLR (PLR ≤ 190: 19.4% vs. PLR &gt; 190: 5.2%) (both P &lt; 0.05). On multivariate survival analyses, PLR remained a predictor of RFS (HR 1.72), while NLR was associated with both DSS (HR 2.21) and RFS (HR 1.99) (both P &lt; 0.05).ConclusionsImmune markers such as NLR and PLR may be useful to stratify patients with regards to prognosis following surgery for ACC