Single Surgeon Experience with 500 Cases of the Robotic Bilateral Axillary Breast Approach (BABA) for Thyroid Surgery Using the Da-Vinci Xi System

Objectives: Robotic bilateral axillary breast approach (BABA) thyroid surgery began in 2008 and is now one of the most widely used remote-access thyroid surgeries worldwide. This study aimed to analyze the results of 500 robotic BABA thyroid surgeries performed in a single institution in Korea compared with open thyroid surgery. Methods: From December 2018 to March 2020, 502 robotic BABA thyroidectomies (RTs) and 531 conventional open thyroidectomies (OTs) were performed in our institution by a single endocrine surgeon. We retrospectively reviewed patient medical records and performed a comparative analysis of OT and RT. Results: The RT group was younger (43.41 ± 11.41 versus 54.28 ± 13.41 years, p < 0.001) and had a higher proportion of females (84.3% versus 69.3%, p < 0.001), a lower BMI (24.66 ± 3.97 versus 25.83 ± 4.07 kg/m2), a higher proportion of lobectomies (52.6% versus 45.2%) and a lower proportion of lateral neck dissections (3.4% versus 10.0%, p < 0.001). The RT group had a longer operation time (145.33 ± 40.80 versus 93.39 ± 43.55 min, p < 0.001) and higher surgical costs. Although the OT group had a larger tumor size and a higher proportion of extrathyroidal extension, the numbers of retrieved lymph nodes were not significantly different between the two groups. Additionally, there was no difference in the stimulated thyroglobulin level before radioactive iodine therapy (7.01 ± 35.73 versus 8.39 ± 58.77, p = 0.782). The rates of transient vocal cord palsy and transient hypoparathyroidism were significantly lower in the RT group, and those of scar-related complications were higher in the OT group. Conclusions: Robotic BABA thyroid surgery has advantages not only in better cosmetic outcomes but also in lower rates of vocal cord palsy and hypoparathyroidism, with comparable lymph node retrieval and serum thyroglobulin levels.

Understanding the Pathogenesis of Gestational Hypothyroidism

Pregnancy is a complex state with many endocrinological challenges to a woman’s physiology. Gestational Hypothyroidism (GHT) is an emerging condition where insufficiency of the thyroid gland has developed during pregnancy in a previously euthyroid woman. It is different to overt hypothyroidism, where marked elevation of thyroid-stimulating hormone with corresponding reduction in free thyroxine levels, is well known to cause detrimental effects to both the mother and the baby. During the past couple of decades, it has been shown that GHT is associated with multiple adverse maternal and fetal outcomes such as miscarriage, pre-eclampsia, placental abruption, fetal loss, premature delivery, neurocognitive and neurobehavioral development. However, three randomized controlled trials and a prospective cohort study performed within the last decade, show that there is no neurodevelopmental improvement in the offspring of mothers who received levothyroxine treatment for GHT. Thus, the benefit of initiating treatment for GHT is highly debated within the clinical community as there may also be risks associated with over-treatment. In addition, regulatory mechanisms that could possibly lead to GHT during pregnancy are not well elucidated. This review aims to unravel pregnancy induced physiological challenges that could provide basis for the development of GHT. During pregnancy, there is increased renal clearance of iodine leading to low iodine state. Also, an elevated estrogen level leading to an increase in circulating thyroglobulin level and a decrease in free thyroxine level. Moreover, placenta secretes compounds such as human chorionic gonadotropin (hCG), placental growth factor (PIGF) and soluble FMS-like tyrosine kinase-1 (s-Flt1) that could affect the thyroid function. In turn, the passage of thyroid hormones and iodine to the fetus is highly regulated within the placental barrier. Together, these mechanisms are hypothesized to contribute to the development of intolerance of thyroid function leading to GHT in a vulnerable individual.

The Ratio of Thyroglobulin in Wash-Out Fluid From Fine-Needle Aspiration to Serum Thyroglobulin Level in the Evaluation of Metastatic Cervical Lymph Nodes in Patients With Papillary Thyroid Cancer

Fine needle aspiration with cytology analysis and thyroglobulin level of the aspirated biopsy (FNAB-Tg), is an important tool to assess metastasis to cervical lymph nodes (CLN) in patients with papillary thyroid cancer (PTC) who have suspicious lymph node features on ultrasound. Despite the great diagnostic accuracy of the FNAB-Tg, studies failed to define the best cutoff value for FNAB-Tg. In our study, we describe a novel way in performing the Tg washout and process it locally at our laboratory (tertiary care center). We used the FNAB-Tg to serum thyroglobulin level (FNAB-Tg/ Tg serum) ratio to help overcome the heterogeneity in both cutoff values and the assays used to detect thyroglobulin level. We conducted a retrospective analysis of 22 PTC or suspected PTC patients, who have suspicious cervical lymph nodes on ultrasound. All patients underwent fine-needle aspiration, with cytology analysis and FNAB-Tg from the suspicious CLNs. FNAB-Tg was obtained in all subjects using the following method: Blood samples are drawn from the patient’s peripheral vein and placed in two yellow top tubes (3 ml of blood in each tube). 1 ml of normal saline (NS) is added to Tube # 1 (Tg Serum tube). The suspected lymph node aspirate is obtained via US-guided FNA. It is washed in 1 ml of NS and added to tube #2 (FNAB-Tg washout tube). Both tubes are sent to our local laboratory for Tg assay. The FNAB-Tg/ Tg serum ratio is calculated. If FNAB-Tg/Serum-Tg ratio&gt;3, this is suggestive of CNL metastasis. We compared our results to the histopathology reports after neck dissection.59% (13/22) patients had cytology results consistent with metastatic PTC. 12 out of these 13 patients had an FNAB-Tg/serum Tg ratio &gt;3 and one had FNAB-Tg/serum TG ratio &lt; 3, though the FNAB-Tg was 4474 ng/ml and serum Tg was 2444 ng/ml. Metastatic PTC to these CLNs was confirmed on pathology report from total thyroidectomy or neck dissection. Six patients of the 22 studied (27%) had negative cytology with FNAB-Tg/serum Tg ratio &gt; 3. 5 of these patients underwent neck dissection in our institute and confirmed to have metastatic PTC to these CLNs. One patient elected to have surgery in his home country and the pathology report is not available at this time. Three patients of the 22 studied (14%) had negative cytology and FNAB-Tg/serum Tg ratio &lt;3. 2 of them underwent thyroid surgery or neck dissection and the final pathology report was concordant with the FNAB-Tg results. The FNAB-Tg/serum Tg ratio is a novel method to overcome the differences in cutoff values and assays used to measure the Tg level both in serum and FNAB. An FNAB–Tg/serum Tg ratio &gt;3 is more accurate than cytology in detecting cervical lymph node metastasis in patients with papillary thyroid cancer (PTC). In our study, 27% of CLN metastasis would have been missed if FNAB cytology was used alone. This will help to optimize the surgical approach in patients with PTC before initial surgery or for suspected recurrence.

Serum thyroglobulin level in newly detected thyrotoxicosis and its role in differential diagnosis of thyrotoxicosis

Background: Elevated serum thyroglobulin (Tg) level is commonly observed in various forms of thyrotoxicosis; the levels vary according to different etiologies. This study aimed at identifying the value of serum Tg level in the differential diagnosis of common etiologies of thyrotoxicosis. Methods: This cross-sectional study was conducted at the endocrine outpatient department of a tertiary hospital in Bangladesh from March 2015 to May 2017. In this study, 200 subjects with newly detected untreated thyrotoxicosis were evaluated. Serum Tg was assayed by chemiluminescent immunometric assay. Results: Serum Tg level was raised in 48% of subjects. Subjects aged ≥40 years, and those having a family history of thyroid disorders had relatively higher thyroglobulin levels. The frequency of subjects with an elevated Tg was highest in subacute thyroiditis (89.5%) followed by toxic nodular goiter (77.3%) and Graves’ disease (32.9%); the difference in the frequencies was statistically significant (p<0.001). Median Tg was highest in the subjects with subacute thyroiditis (132.6 ng/ml) followed by toxic nodular goiter (99.55 ng/ml); those with Graves’ disease had the lowest Tg level (12.5 ng/ml); the differences in median Tg levels across the three groups were also statistically significant (p<0.001). Conclusions: Serum thyroglobulin level may be useful for the etiological diagnosis of thyrotoxicosis.

SERUM THYROGLOBULIN AND ANTI THYROGLOBULIN LEVELS IN PATIENTS WITH THYROID NODULES

Objectives: To compare the levels and pathological values of serum Tg and TgAb between the patients with benign and malignant thyroid nodules and evaluate the relationship between serum Tg and TgAb levels with the rim characteristic and elasticity score of the nodule by thyroid elasto-echography. Subjects: 30 patients with thyroid nodules, Serum Tg and TgAb levels and thyroid elasto-echography are examen before operation. Results: The ratio of the positive Tg level of malignant thyroid nodules was higher than the benign thyroid nodules (16.7% vs 8.3%) but the serum Tg level was not significantly different (33.48 ± 38.67 ng/ml vs 27.32 ± 28.44 ng/ml, p > 0.05) and The ratio of positive TgAb level of malignant thyroid nodules was higher than that of benign thyroid nodules (22.2% vs 0%) but serum TgAb level was not different (64.15 ± 14.91 UI/ml vs 16.9 ± 14.48 UI/ml, p > 0.05). The combination of the ratio of positive Tg and positive TgAb level did not show any difference in the ratio of pathological value between benign and malignant thyroid nodules (5.6% vs 0%). Serum Tg levels in patients with irregular rim thyroid nodules were higher than those in patients with regular rim thyroid nodules but the serum Tg level was not different when evaluated with the elastic score. Conclusions: The mean level and ratio of the pathological value of serum Tg and TgAb did not differ between malignant and benign thyroid nodules. There is a relationship between serum Tg level and irregular rim characteristic of thyroid nodule (p < 0.05). Key words: serum thyroglobulin level, serum anti thyroglobulin level, thyroid nodule.

Current iodine nutrition status in Poland (2017): is the Polish model of obligatory iodine prophylaxis able to eliminate iodine deficiency in the population?

Objective:The monitoring of the populations’ iodine status is an essential part of successful programmes of iodine deficiency elimination. The current study aimed at the evaluation of current iodine nutrition in school children, pregnant and lactating women as a marker of the effectiveness and sustainability of mandatory iodine prophylaxis in Poland.Design:The following iodine nutrition indicators were used: urinary iodine concentration (UIC) (all participants) and serum thyroglobulin (pregnant and lactating women).Setting:The study was conducted in 2017 within the National Health Programme in five regions of Poland.Participants:The research included 300 pregnant women, 100 lactating women and 1000 school children (aged 6–12 years).Results:In pregnant women, median UIC was 111·6 µg/l; there was no significant difference in median UIC according to the region of residence. In 8 % of pregnant women, thyroglobulin level was >40 ng/ml (median thyroglobulin 13·3 ng/ml). In lactating women, median UIC was 68·0 µg/l. A significant inter-regional difference was noted (P = 0·0143). In 18 % of breastfeeding women, thyroglobulin level was >40 ng/ml (median thyroglobulin 18·5 ng/ml). According to the WHO criteria, the investigated sample of pregnant and lactating women was iodine-deficient. Median UIC in school children was 119·8 µg/l (with significant inter-regional variation; P = 0·0000), which is consistent with iodine sufficiency. Ninety-four children (9·4 %) had UIC < 50 µg/l.Conclusions:Mandatory iodisation of household salt in Poland has led to a sustainable optimisation of iodine status in the general population. However, it has failed to assure adequate iodine nutrition during pregnancy and lactation.