Thyroid

Management of lateral cervical metastases in papillary thyroid cancer: Patterns of lymph node distribution

August 15, 2011     J. Michael King, MD, Christian Corbitt, MD, and Frank R. Miller, MD, FACS
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Abstract

In this article we discuss the management of lateral cervical lymph node metastases in papillary thyroid cancer (PTC). We conducted a retrospective analysis of cases of PTC at our tertiary academic medical center involving 32 patients who underwent 39 neck dissections for the management of lateral cervical metastases from 2000 to 2007. Of these patients, 18 underwent primary neck dissections at the time of thyroidectomy after fine-needle aspiration biopsy confirmed the PTC. Secondary neck dissections for delayed metastases were performed in 14 patients who had previously undergone thyroidectomy for confirmed PTC. All 32 patients had positive nodes in at least one level. Our results highlight the high incidence of multilevel cervical metastasis associated with PTC and suggest the importance of including level II-B (submuscular recess) when performing a neck dissection; the upper posterior triangle (level V-A) is less likely to harbor occult tumor. Lateral neck metastasis from PTC is common and predictable; locoregional control is improved with a formal, comprehensive neck dissection at the time of thyroidectomy.

Thyroidectomy for goiter relieves obstructive sleep apnea: Results of 8 cases

July 13, 2011     Mark T. Agrama, MD
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Abstract

The author conducted a retrospective study of 8 adults with euthyroid goiter that had resulted in tracheal compression and led to moderate to severe obstructive sleep apnea (OSA). The purpose of the study was to evaluate the effects of thyroidectomy on the apnea-hypopnea index (AHI) in these patients and to determine if there is a relationship between tracheal compression and OSA. These patients had been treated by the author in a community hospital over a 4-year period. All 8 patients had reported compressive symptoms of orthopnea and dysphagia, and 3 of them also reported dyspnea. Computed tomography of the neck and chest had been used to confirm the extent of goiter and tracheal compression. OSA had been confirmed with preoperative polysomnography. At 90 days post-thyroidectomy, repeat polysomnography had been obtained. At follow-up, all 8 patients had reported symptomatic control of compressive symptoms, and 7 patients had demonstrated postoperative improvement in their AHI. Overall, the mean postoperative AHI had decreased from 52.1 to 36.6-a statistically significant reduction of 29.8% (p < 0.05). The results of this study suggest that thyroidectomy for tracheal compression secondary to goiter can significantly alleviate symptoms and improve AHI in those patients who experience OSA. Evaluation of all patients with OSA should include screening for goiter-induced tracheal compression.

Kikuchi disease and thyroid follicular adenoma

August 31, 2010     Mohamed Abdel Khalek, MD, Xin Zhong, BS, Krzysztof Moroz, MD, and Emad Kandil, MD
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Predicting hypocalcemia after total thyroidectomy: Parathyroid hormone level vs. serial calcium levels

August 31, 2010     Adam T. Graff, MD, Frank R. Miller, MD, FACS, Corrie E. Roehm, MD, and Thomas J. Prihoda, PhD
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Abstract

A 24- to 48-hour in-hospital observation period to monitor for hypocalcemia is common after total thyroidectomy. Because most thyroidectomy patients do not experience this potentially serious complication, investigators have searched for methods and clinical indicators that may help stratify thyroidectomy patients according to their risk of developing hypocalcemia and identify those who can be safely discharged earlier. We conducted a retrospective study to compare the value of an immediate postoperative intact parathyroid hormone (PTH) level and serial calcium levels in predicting the development of hypocalcemia following total thyroidectomy. Our study population was made up of 69 consecutive patients who had undergone total thyroidectomy from January 2004 through March 2005. These patients were divided into two groups on the basis of their postoperative calcium levels; 11 patients (16%) had developed transient hypocalcemia (serum calcium level: <7.5 mg/dl) and 58 (84%) had remained normocalcemic. A model was developed to assess the relationship between early (<60 min) postoperative PTH levels and serial (6 and 18 hr) calcium levels, and the two-sample Student t test was used to identify differences between the two groups. Analysis showed that hypocalcemia was associated with a postoperative PTH level of less than 14 pg/ml and a negative serum calcium slope between 6 and 18 hours postoperatively. A single early postoperative intact PTH measurement may be the most cost-effective screening tool for hypocalcemia, but even greater specificity can be achieved by combining those findings with a serum calcium measurement taken 6 hours postoperatively. The combination of the two measurements represents the safest method of assessing risk and identifying those patients who can be discharged on the day of surgery.

Medullary thyroid carcinoma

June 30, 2010     Lester D.R. Thompson, MD
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Papillary carcinoma arising in median ectopic thyroid tissue: Management of the thyroid gland

April 30, 2010     Susan Cordes, MD and Jeffrey J. Nelson, MD
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Abstract

Thyroid tissue in an ectopic location is rare, 1 in 100,000 to 300,000 persons, and usually in the lateral neck. Median ectopic thyroid tissue is even more unusual, with the vast majority of cases being lingual thyroid tissue. We present a case of carcinoma arising in median, nonlingual ectopic thyroid tissue along with an analysis of the literature to determine the most appropriate management of the orthotopic thyroid gland.

Type I thyroplasty revision 1 year after a window was mistakenly created on the cricoid cartilage

April 30, 2010     Hilmi Alper &Scedil;enkal, MD and Taner Yilmaz, MD
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Abstract

Unilateral vocal fold paralysis causes glottic incompetence and can result in significant morbidity. To prevent such morbidity, surgeons treat affected patients with vocal fold medialization techniques; type I thyroplasty medialization surgery is widely used for this purpose. In this procedure, a window is opened on the thyroid cartilage to allow for placement of a silicon prosthesis to medialize the vocal fold. A 38-year-old woman presented to our clinic for evaluation of hoarseness and a low-pitched voice, which we diagnosed as being caused by left vocal fold paralysis. Two years earlier, she had undergone a thyroidectomy for the treatment of benign thyroid disease. One year after that, she underwent type I thyroplasty medialization surgery at another center. During that operation, the surgeon had mistakenly created the window on the cricoid cartilage rather than the thyroid cartilage. When he inserted the silicon prosthesis into the cricoid window, the patient developed acute respiratory obstruction. At that point, the prosthesis was removed and the operation was terminated. One year later, she presented to us, and we performed a revision type I thyroplasty. Intraoperatively, we discovered that the original window had been opened on the cricoid cartilage instead of the thyroid cartilage, which was intact. We left the cricoid window untouched, opened a new window on the thyroid cartilage, and completed the type I thyroplasty in the usual fashion. The patient's postoperative recovery was uneventful, and she was doing well at 5 years of follow-up. To the best of our knowledge, no case of a thyroplasty window being opened on a cricoid cartilage has been reported in the literature.

Disseminated plasmacytoma of the thyroid

March 1, 2010     Brian J. Park, MD, MPH, Randy J. Kalish, MD, and Arthur P. Vercillo, MD
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Abstract

Extramedullary plasmacytomas most commonly occur in the nasal cavity, nasopharynx, paranasal sinuses, and larynx. Thyroid involvement is rare, as fewer than 75 cases have been previously reported in the literature. We report a new case of disseminated plasmacytoma of the thyroid, which occurred in a 68-year-old woman. The diagnosis was made with an incisional biopsy. The patient initially experienced a complete response to radiotherapy (46.8 Gy in 26 fractions), but she developed multiple metastases at distant sites, including the breast, abdominal wall, and buttock despite various chemotherapy regimens. Ultimately, she was placed on palliative radiotherapy. We also briefly review the diagnostic and treatment options for patients with extramedullary plasmacytoma.

Parathyroid carcinoma: A rare cause of primary hyperparathyroidism

August 31, 2009     Brian Kung, MD, Ronald Winokur, MD, David Cognetti, MD, Brian O'Hara, MD, and David Rosen, MD
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Abstract

Most cases of primary hyperparathyroidism (80 to 90%) are caused by a parathyroid adenoma; most of the rest are caused by either parathyroid gland hyperplasia or multiple adenomas. Parathyroid carcinoma can be the cause of primary hyperparathyroidism in 1 to 5% of patients. When the appropriate clinical scenario is presented, it must be considered in the differential diagnosis. We describe the case of a 72-year-old woman with a long history of hypercalcemia and arthritic shoulder and neck pain who was admitted with an elevated calcium level and acute renal failure secondary to bilateral obstructing ureteral calculi. A sestamibi scan and magnetic resonance imaging detected the presence of what appeared to be a right inferior parathyroid adenoma. Her intact parathyroid hormone (PTH) level was 2,257 pg/ml. Following placement of bilateral ureteral stents and adequate hydration, the patient was taken to the operating room for a neck exploration and removal of a parathyroid adenoma with rapid intraoperative PTH monitoring. A 4 x 2.5-cm, 10-g mass was removed from the right inferior pole of the thyroid gland. Following excision, her intraoperative PTH level dropped from 1,103 to 110 pg/ml. Her ionized calcium levels fell from a high of 8.4 mg/dl preoperatively to 4.7 mg/dl. On final pathologic examination, the mass was confirmed to be a parathyroid carcinoma.

Adjuvant external-beam radiotherapy in patients with high-risk well-differentiated thyroid cancer

June 30, 2009     Peter V. Chen, MD, MS, Ryan Osborne, MD, Eugene Ahn, MD, Sofia Avitia, MD, Elliot Abemayor, MD, PhD, and Guy Juillard, MD
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Abstract

The role of adjuvant external-beam radiation therapy (EBRT) in well-differentiated thyroid cancer is not well delineated. Many clinicians rely solely on iodine 131 (131I) to destroy thyroid remnants following thyroidectomy. However, the lesser uptake of isotope in tumor cells suggests that 131I alone may not be sufficient to eradicate microscopic residual disease when no gross thyroid tissue remains. We conducted a retrospective study to examine the potential benefit of adjuvant EBRT in patients at high risk for microscopic residual disease following thyroidectomy. Between 1973 and 2001, 44 patients with well-differentiated papillary or follicular thyroid cancer were found to have extracapsular extension following thyroidectomy. These patients were divided into 2 groups based on the type of treatment; 11 patients had received adjuvant EBRT (with or without 131I) and 33 patients had not received EBRT (i.e., they received adjuvant 131I only). We reviewed their medical records and compiled data on local recurrence and overall survival (Kaplan-Meier analysis). Despite having a less favorable prognosis, the EBRT group experienced no local recurrences during a mean follow-up of 7.8 years; in contrast, 9 local recurrences were seen in the no-EBRT group. Also, the median survival for patients without a local recurrence was longer than that for those who had failed locally (425 vs. 317 mo). Although our population was not large enough for these differences to achieve statistical significance, our study did show that adjuvant EBRT provided excellent results. We hypothesize that a reciprocal irradiation effect between cancer cells and normal cells may be necessary in order for 131I to be tumoricidal. If so, a patient with microscopic residual disease would not have enough cancer cells to sufficiently concentrate 131I. Because EBRT does not depend on such a mechanism, it may be more effective than 131I in controlling disease in the setting of microscopic disease. Larger studies are needed to validate our results. In the meantime, we believe that adjuvant EBRT should play an important role in the treatment of patients with high-risk well-differentiated thyroid cancer.

Follicular variant of papillary carcinoma arising from lingual thyroid

May 31, 2009     Churunal K. Hari, FRCS, Manoj Kumar, FRCS, Mohamed M. Abo-Khatwa, FRCS, Julia Adams-Williams, MRCS, and Hisham Zeitoun, MPhil, FRCS
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Abstract

Malignant transformation of ectopic lingual thyroid tissue is an uncommon event; only 43 cases have been reported in the literature. Only 10 of these cases were papillary carcinomas, in contrast to normal thyroid gland neoplasms, of which papillary tumors form the predominant group. We present a case of a follicular variant of papillary carcinoma originating from the lingual thyroid, along with a review of the literature. Our patient was treated with surgical excision followed by 131I therapy. To date, only 2 other cases of a follicular variant of lingual thyroid tumor have been reported.

Lingual thyroid

May 31, 2009     Manish Gupta, MS and Gul Motwani, MS
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Abstract

Lingual thyroid gland is a rare clinical entity caused by failure of the gland's anlage to descend early in the course of embryogenesis. It may present with symptoms of dysphagia, upper airway obstruction, or even hemorrhage anytime from infancy through adulthood. Treatment of this disorder includes the use of exogenous thyroid hormone to correct the hypothyroidism and to induce shrinkage of the gland. When symptoms of obstruction or bleeding appear, ablative therapy by means of surgery or radioiodine is warranted. We report our experience with lingual thyroid gland and discuss elements of the diagnostic and therapeutic evaluation, with emphasis on the clinical findings, laboratory tests, and radiographic imaging studies.

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