Robbins Pathologic Basis of Disease

Objective:To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.Background:Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in th

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

FIBROCYSTIC CHANGES (FCC) are a group of alterations in the female breast ranging from harmless to those associated with an increased risk of breast c rcinoma. Some of these changes (stromal fibrosis a nd microcysts or macrocysts) produce palpable lumps. F CC are in essence an exaggeration and distortion of the cyclic breast changes that occur normally in the menstrual cycle. Traditionally, these breast alterations have been called fibrocystic disease. However, most of the changes included within this d iagnosis have little clinical significance except that they cause nodularity; onl y a small minority (epithelial hyperplasia) are cli nically important. Thus, the term FCC is preferred, since i t does not mark the subject with a disease. The lum ps produced by the various patterns of fibrocystic cha nge must be distinguished from cancer, and the dist inction between the unimportant variants and the more signi fica t ones can be made by examination of fine-need le aspiration material or more definitively by biopsy and histologic evaluation. The alterations encounte red within the FCC are subdivided into 1. Nonproliferative (simple FCC) that include cysts &/or fibrosis (the most common) 2. Proliferative that include a range of harmless to atypical epith lial cell hyperplasias of the ducts or ductules as well as sclerosing adenosis . All the entities within FCC tend to arise during re p oductive period of life but may persist after men opause. The various changes, particularly the nonproliferative ones, are so common, being found at autopsy in up to 80% of women, that they almost constitute physiologic variants. Cysts and Fibrosis : (Fig. 11-2) characterized by an increase in fibrous stroma asso ciated with dilation of ducts and formation of cysts of various sizes. Grossly, a single large cyst may form within one breast, b u the disorder is usually multifocal and often bilateral. The cyst s are up to 5 cm in diameter. Unopened, they are br own to blue (blue dome cysts) and are filled with serous, turbi d fluid. Microscopically, in smaller cysts, the epithelium is cuboidal to columnar. In larger cysts it may be fla ttened. Frequently, cysts are lined by large cells with abundant granular, eosinophilic cytoplasm, with small, round , deeply stained nuclei; this is called apocrine metaplasia, which is virtually always benign.  Proliferative Changes  1. Epithelial Hyperplasia comprises a range of proliferative lesions within the ductule s, the terminal ducts (ductal hyperplasia), and sometimes the lobules (lo bular hyperplasia) of the breast. Some of the epith lial hyperplasias are mild and carry little risk of carc inoma, but others are the more florid and atypical th t carry a significantly greater risk. Microscopically, the ducts, ductules, or lobules may be filled wit h cuboidal cells, within which small glands are disposed (fenestratio ns) (Fig. 11-3). The degree of hyperplasia can be mild, moderate, or severe. In some instances the hyperplastic cells show compl ex architectural patterns and approaching morphologically those of ductal carcino ma in situ, such hyperplasia is called atypical. The line separating the epithelial hyperplasias without atypia from atypical hyperplasia is difficult to define, just as it is difficult to clearly distinguish between atypical hyperplasia and carcinoma in situ. Atypical lobular hyperplasia (Fig. 11-4) describes hyperplasias that cytologically resembl lobular carcinoma in situ, but the cells do not fill or distend more than 50% of the acini within a lobule. Atypical lobular hyperplasia is associated with an increased risk of invasive carcinoma.

Pathology of the breast

BACKGROUND Hypoparathyroidism, the most common complication after thyroid surgery, leads to hypocalcaemia and significant medical problems. An RCT was undertaken to determine whether intraoperative parathyroid gland angiography with indocyanine green (ICG) could predict postoperative hypoparathyroidism, and obviate the need for systematic blood tests and oral calcium supplementation. METHODS Between September 2014 and February 2016, patients who had at least one well perfused parathyroid gland on ICG angiography were randomized to receive standard follow-up (measurement of calcium and parathyroid hormone (PTH) on postoperative day (POD) 1 and systematic supplementation with calcium and vitamin D; control group) or no supplementation and no blood test on POD 1 (intervention group). In all patients, calcium and PTH levels were measured 10-15 days after thyroidectomy. The primary endpoint was hypocalcaemia on POD 10-15. RESULTS A total of 196 patients underwent ICG angiography during thyroid surgery, of whom 146 had at least one well perfused parathyroid gland on ICG angiography and were randomized. None of these patients presented with hypoparathyroidism, including those who did not receive calcium supplementation. The intervention group was statistically non-inferior to the control group (exact 95 per cent c.i. of the difference in proportion of patients with hypocalcaemia -0·053 to 0·053; P = 0·012). Eleven of the 50 excluded patients, in whom no well perfused parathyroid gland could be identified by angiography, presented with hypoparathyroidism on POD 1, and six on POD 10-15, which was significantly different from the findings in randomized patients (P = 0·007). CONCLUSION ICG angiography reliably predicts the vascularization of the parathyroid glands and obviates the need for postoperative measurement of calcium and PTH, and supplementation with calcium in patients with at least one well perfused parathyroid gland. Registration number: NCT02249780 (http://www.clinicaltrials.gov).

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Randomized clinical trial of intraoperative parathyroid gland angiography with indocyanine green fluorescence predicting parathyroid function after thyroid surgery.

Lateral lymph node metastasis in papillary thyroid carcinoma: A systematic review and meta-analysis for prevalence, risk factors, and location.

Because lymph node (LN) metastasis has been proven to be a predictor for locoregional recurrence (LRR) in papillary thyroid microcarcinoma (PTMC), better knowledge about the predictors for LN metastasis in PTMC is required. We retrospectively reviewed 5656 PTMC patients who underwent total thyroidectomy and central neck dissection and/or lateral neck dissection between January 1997 and June 2015. Male gender (adjusted odds ratio [OR] 2.332), conventional variant (adjusted OR 4.266), tumor size >0.5 cm (adjusted OR 1.753), multiplicity (adjusted OR 1.168), bilaterality (adjusted OR 1.177), and extrathyroidal extension (ETE) (adjusted OR 1.448) were independent predictors for high prevalence of central LN metastasis (CLNM), whereas per 10-year age increment (adjusted OR 0.760) and chronic lymphocytic thyroiditis (adjusted OR 0.791) were independent predictors for low prevalence of CLNM. In addition, male gender (adjusted OR 1.489), tumor size >0.5 cm (adjusted OR 1.295), multiplicity (adjusted OR 1.801), ETE (adjusted OR 1.659), and CLNM (adjusted OR 4.359) were independent predictors for high prevalence of lateral LN metastasis (LLNM), whereas per 10-year age increment (adjusted OR 0.838) was an independent predictor for low prevalence of LLNM. There was a statistically significant difference in LRR with regard to nodal stage (p < 0.001). Meticulous perioperative evaluation of LN metastasis is required for PTMC patients with the above predictors.

Predictive Factors for Lymph Node Metastasis in Papillary Thyroid Microcarcinoma

Total thyroidectomy versus lobectomy in conventional papillary thyroid microcarcinoma: Analysis of 8,676 patients at a single institution

Background
The failure to preserve parathyroid function in patients who have undergone total thyroidectomy is of major concern, because hypocalcemia is difficult to prevent and remains a common postoperative complication. Here, we describe procedures designed to preserve the vasculature supplying the parathyroid glands and examine both recent outcomes and retrospective reports of results obtained prior to the application of these preservation techniques.

Preserving Parathyroid Gland Vasculature to Reduce Post-thyroidectomy Hypocalcemia.

Background The benefits of prophylactic central neck dissection (pCND) remain controversial in clinically node-negative (cN0) papillary thyroid carcinoma (PTC). The purpose of this study was to investigate the clinical impact of pCND with a large group of cN0 PTC patients. Study Design A total of 11,569 cN0 PTC patients who underwent thyroidectomy between January 1997 and June 2015 were investigated. Using Cox multivariate analysis, the prognostic impact of pCND was assessed using subset analyses according to various clinicopathologic conditions. Using propensity score matching, various surgical morbidities were assessed under adjusted conditions. Results Of 11,569 cN0 PTC patients, 8,735 (75.5%) underwent pCND. Prophylactic CND did not significantly decrease the risk of locoregional recurrence in cN0 PTC patients (adjusted hazard ratio [HR] = 0.874; p = 0.392). In addition, pCND did not significantly decrease the risk of locoregional recurrence in various surgical extents (lobectomy and ipsilateral pCND [adjusted HR = 0.636; p = 0.131], total thyroidectomy and ipsilateral pCND [adjusted HR = 0.775; p = 0.164], and total thyroidectomy and bilateral pCND [adjusted HR = 1.041; p = 0.821]). However, surgical morbidities, such as temporary vocal cord palsy (5.6% vs 2.5%; p = 0.001), temporary hypoparathyroidism (30.8% vs 16.7%; p Conclusions Given the lack of proven benefits and the clear evidence of morbidities, pCND cannot be recommended as a routine procedure. We suggest that CND be reserved for therapeutic situations.

Prophylactic Central Neck Dissection Might Not Be Necessary in Papillary Thyroid Carcinoma: Analysis of 11,569 Cases from a Single Institution

It has been reported that papillary thyroid carcinoma (PTC) with chronic lymphocytic thyroiditis (CLT) is less associated with extrathyroidal extension (ETE), advanced tumor stage and lymph node (LN) metastasis. Other studies have suggested that concurrent CLT could antagonize PTC progression, even in BRAF-positive patients. Since the clinical significance of the BRAF mutation has been particularly associated with conventional PTC, the purpose of this study was to determine the clinical significance of CLT according to BRAF mutation status in conventional PTC patients. We retrospectively reviewed the medical records of 3332 conventional PTC patients who underwent total thyroidectomy with bilateral central neck dissection at the Thyroid Cancer Center of Samsung Medical Center between January 2008 and June 2015. In this study, the prevalence of BRAF mutation was significantly less frequent in conventional PTC patients with CLT (76.9% vs 86.6%). CLT was an independent predictor for low prevalence of ETE in both BRAF-negative (OR=0.662, P=0.023) and BRAF-positive (OR=0.817, P=0.027) conventional PTC patients. In addition, CLT was an independent predictor for low prevalence of CLNM in both BRAF-negative (OR=0.675, P=0.044) and BRAF-positive (OR=0.817, P=0.030) conventional PTC patients. In conclusion, BRAF mutation was significantly less frequent in conventional PTC patients with CLT. However, CLT was an independent predictor for less aggressiveness in conventional PTC patients regardless of BRAF mutation status.

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Inhye Park

Papers

Predictive Factors for Lymph Node Metastasis in Papillary Thyroid Microcarcinoma

Total thyroidectomy versus lobectomy in conventional papillary thyroid microcarcinoma: Analysis of 8,676 patients at a single institution

Preserving Parathyroid Gland Vasculature to Reduce Post-thyroidectomy Hypocalcemia.

Prophylactic Central Neck Dissection Might Not Be Necessary in Papillary Thyroid Carcinoma: Analysis of 11,569 Cases from a Single Institution

Chronic lymphocytic thyroiditis and BRAF V600E in papillary thyroid carcinoma