Chyle leakage (CL) due to lymphatic injuries is one of the rare complications that can develop after thyroidectomy. There are few studies on lymphatic embolization performed in case of CL after thyroid surgery. We report two cases of CL after thyroid surgery that were effectively treated by thoracic duct embolization. The patients had previously undergone total thyroidectomy with central compartment neck dissection with or without modified radical neck dissection. The amount of drainage from the operative site was ＞1000 mL per day in one patient and ＞500 mL per day in the other. In both cases, CL stopped after the thoracic duct embolization. Thoracic duct embolization seems to be an effective and important treatment option for CL after thyroid surgery.

Thyroid nodules are the most common endocrine tumor. Ultrasonography and fine-needle aspiration (FNA) are currently accurate diagnostic tools for evaluating thyroid nodules. However, 10–30% of FNA specimens are cytologically indeterminate. Making an accurate diagnosis between benign and malignant nodules is important so that patients with malignant nodule receive proper treatment and patients with benign nodule can avoid unnecessary treatment. Several genetic changes such as point mutations of the BRAF or RAS and rearrangements of the RET/PTC1, RET/PTC3, PAX8/PPARY are used to adjust to indeterminate FNA. Such a mutational analysis has an excellent positive predictive value (PPV), but there is a weakness in the low negative predictive value (NPV). Gene-expression classifier (GEC) has been found helpful in identify nodules that are benign rather than malignant. GEC has an excellent NPV, but there is a weakness of low PPV. Multiplatform mutational and miRNA test (MPT) and next-generation sequencing assay (NGS) are being studied to compensate for these weaknesses. Molecular tests appear to be a good solution for improving the accuracy of indeterminate FNA cytology specimens and support the clinical management decisions in patients with indeterminate cytologic nodules, but further prospective multicenter trials are required for validation of reported findings and need evaluation of cost-effectiveness. This paper will review recently available molecular diagnostic tools of thyroid nodule.
Biopsy, Fine-Needle ; Diagnosis ; Humans ; MicroRNAs ; Multicenter Studies as Topic ; Pathology, Molecular ; Point Mutation ; Prospective Studies ; Thyroid Gland ; Thyroid Neoplasms ; Thyroid Nodule ; Ultrasonography

BACKGROUND/OBJECTIVES: Papillary thyroid carcinoma (PTC) has generally an indolent character with a good prognosis. However, recurrence remains a major concern for the patients during their lifetime. Despite the slowly progressing character of PTC, recurrence can occur within a short period after initial surgery.This study aimed to determine the clinical findings and cause of recurrence in patients who underwent re-operative surgery due to neck node recurrence by reviewing the CT (computed tomographic) scan imaging of the recurrence of PTC retrospectively.MATERIALS #SPCHAR_X0026; METHODS: We reviewed the medical records of patients referred to Ajou University Hospital from January 2002 to January 2018. All patients had re-operative surgery due to neck node recurrence and CT scan results of preoperative evaluation and postoperative follow up. Over this period, 110 patients who underwent re-operation due to neck node recurrence with a CT scan were included in our cohort, resulting in a total of 220 re-operations.RESULTS: The time from initial operation to first re-operation was examined in 110 patients. The median time to re-operation was 28 months, with a range of 4 months to 186 months. Most re-operations (82.7%) occurred within the first five years, 43.6% were in the first two years from the initial surgery. The result of the retrospective CT review showed newly developed cases (21,19.1%), missed diagnosis cases (42,38.2%), real recur cases after surgery (33,30.0%), and remnant lymph nodes (LNs) cases (14,12.7%). We further sub-analyzed 14 cases with remnant LNs. Reasons for remnant LNs included insufficient operation (N=5) and beyond general surgical extent. (N=9).CONCLUSION: Re-operation due to cervical lymph node recurrence is mostly a persistent disease. They included a missed diagnosis and incomplete operation. These finding may reduce the reoperation of cervical lymph node recurrence by accurate preoperative evaluation and complete surgical resection at the initial surgery.
Cohort Studies ; Diagnosis ; Follow-Up Studies ; Humans ; Lymph Nodes ; Medical Records ; Neck ; Prognosis ; Recurrence ; Reoperation ; Retrospective Studies ; Thyroid Gland ; Thyroid Neoplasms ; Tomography, X-Ray Computed

BACKGROUND: Recently, VE1, a monoclonal antibody against the BRAFV600E mutant protein, has been investigated in terms of its detection of the BRAFV600E mutation. Although VE1 immunostaining and molecular methods used to assess papillary thyroid carcinoma in surgical specimens are in good agreement, evaluation of VE1 in thyroid cytology samples is rarely performed, and its diagnostic value in cytology has not been well established. In present study, we explored VE1 immunoexpression in cytology samples from ex vivo papillary thyroid carcinoma specimens in order to minimize limitations of low cellularity and sampling/targeting errors originated from thyroid fineneedle aspiration and compared our results with those obtained using the corresponding papillary thyroid carcinoma tissues. METHODS: The VE1 antibody was evaluated in 21 cases of thyroid cytology obtained directly from ex vivo thyroid specimens. VE1 immunostaining was performed using liquid-based cytology, and the results were compared with those obtained using the corresponding tissues. RESULTS: Of 21 cases, 19 classic papillary thyroid carcinomas had BRAFV600E mutations, whereas two follicular variants expressed wild-type BRAF. VE1 immunoexpression varied according to specimen type. In detection of the BRAFV600E mutation, VE1 immunostaining of the surgical specimen exhibited 100% sensitivity and 100% specificity, whereas VE1 immunostaining of the cytology specimen exhibited only 94.7% sensitivity and 0% specificity. CONCLUSIONS: Our data suggest that VE1 immunostaining of a cytology specimen is less specific than that of a surgical specimen for detection of the BRAFV600E mutation, and that VE1 immunostaining of a cytology specimen should be further evaluated and optimized for clinical use.
Biopsy, Fine-Needle ; Immunohistochemistry ; Mutant Proteins ; Sensitivity and Specificity ; Thyroid Gland* ; Thyroid Neoplasms*

Thyroid cancer is a hot issue in Korea because there is debate on screening and diagnosis of thyroid cancer. Therefore, we reviewed the guidelines for the management of thyroid nodules of other countries. Western countries accepted the criteria of fine needle aspiration including the tumor size of thyroid nodules, although ultrasonographic morphologic characteristics are more important to diagnose the thyroid cancer than tumor size. This recommendation is based on good prognosis of papillary thyroid microcarcinoma. However, small subset of papillary thyroid microcarcinoma has aggressive behavior, which we cannot discern from those with benign behavior before operation. Therefore, further researches are necessary to resolve these problems and improve the management of papillary thyroid cancer avoiding overtreatment and mismanagement.
Biopsy, Fine-Needle* ; Diagnosis ; Korea ; Mass Screening ; Prognosis ; Thyroid Gland ; Thyroid Neoplasms ; Thyroid Nodule*

B-RafV600E mutant is found in 40-70% of papillary thyroid carcinoma (PTC) and has an important role in the pathogenesis of PTC. The sodium iodide symporter (NIS) is an integral plasma membrane glycoprotein that mediates active iodide transport into the thyroid follicular cells, and B-RafV600E has been known to be associated with the loss of NIS expression. In this study, we found that B-RafV600E inhibited NIS expression by the upregulation of its promoter methylation, and that specific regions of CpG islands of NIS promoter in B-RafV600E harboring PTC were highly methylated compared with surrounding normal tissue. Although DNA methyltransferase 3a and 3b (DNMT3a,3b) were not increased by B-RafV600E, DNMT1 expression was markedly upregulated in PTC and B-RafV600E expressing thyrocytes. Furthermore, DNMT1 expression was upregulated by B-RafV600E induced NF-kappaB activation. These results led us to conclude that NIS promoter methylation, which was induced by B-RafV600E, is one of the possible mechanisms involved in NIS downregulation in PTC.
Base Sequence ; Carcinoma/*genetics/metabolism/pathology ; Cells, Cultured ; DNA (Cytosine-5-)-Methyltransferase/analysis/*genetics/metabolism ; DNA Methylation ; Down-Regulation ; *Gene Expression Regulation, Neoplastic ; Humans ; Molecular Sequence Data ; *Point Mutation ; Promoter Regions, Genetic ; Proto-Oncogene Proteins B-raf/*genetics/metabolism ; Symporters/analysis/*genetics/metabolism ; Thyroid Gland/cytology/metabolism/pathology ; Thyroid Neoplasms/*genetics/metabolism/pathology ; Up-Regulation

Bilateral chylothoraxis an extremely rare complication of modified radical neck dissection. It is a potentially life-threatening condition that can lead to severe respiratory, nutritional, metabolic, and immunologic disorders. Use of a multi-disciplinary approach including drainage of chyle, reduction of chyle formation, adequate nutritional support, use of somatostatin or its analogue, surgical ligation of the thoracic duct, and thoracic duct embolization is the best method for treatment of bilateral chylothorax. We report on a case of bilateral chylothorax following total thyroidectomy with modified radical neck dissection and discuss its management.
Chyle ; Chylothorax* ; Drainage ; Ligation ; Neck Dissection* ; Nutritional Support ; Somatostatin ; Thoracic Duct ; Thyroid Neoplasms* ; Thyroidectomy

PURPOSE: The goal of this study was to evaluate the diagnostic accuracy of preoperative fine needle aspiration biopsy cytology (FNAB-C) in predicting lateral lymph node metastasis in papillary thyroid cancer patients. METHODS: A total of 592 patients who underwent thyroid cancer surgery and intra-operative lateral cervical LN frozen section or RND, from January 2002 to December 2011, were evaluated retrospectively. Among them, 228 cases had suspicious findings in FNAB-C of lateral nodes. We reviewed their radiological and pathological reports. RESULTS: Intra-operative frozen section examination was performed in 540 cases and RND was performed in 314 cases. This study included 534 women (83.4%) and 106 men (16.6%). Patients' ranged in age from 9 to 83 years (mean, 45.65 years). FNAB-C was performed in 228 cases. The sensitivity and specificity of FNAB-C was 71.5% and 78.6%, respectively; 35.9% of cases had a false negative result. The combination of FNAB-C and intra-operative frozen section test sensitivity and specificity was 87.2% and 93.6%, respectively. CONCLUSION: The results for sensitivity in FNAB-C actually appear low, and false negative results were very high. In papillary thyroid cancer in patients with FNAB-C, even if the result is negative, if lymph node metastasis is suspected based on radiologic evidence, frozen section examination should be performed for determination of metastasis.
Biopsy ; Biopsy, Fine-Needle ; Female ; Frozen Sections ; Humans ; Lymph Nodes ; Male ; Neoplasm Metastasis* ; Retrospective Studies ; Sensitivity and Specificity ; Thyroid Neoplasms*

Papillary thyroid microcarcinoma (PTMC) has been increasing, without a consensus for the management of this condition. In the present study, we analyzed the clinicopathological features of patients with PTMC to examine the impact of initial therapy and establish appropriate treatment. A total of 2,018 patients with PTMC were enrolled at a single university hospital. Of them, 1,245 patients (61.8%) underwent total thyroidectomy, and 1,838 patients (91.3%) underwent central lymph node (LN) dissection. Five-and 10-yr recurrence rates were 3.2% and 4.6%, respectively. In univariate analysis, the prognostic factors for recurrence were N stage, the number of LN metastases, and extrathyroidal extension. However, multivariate analysis revealed LN metastases and N stage as the only significant prognostic factors after adjusting for confounding factors (P < 0.001). Additionally, multivariate analysis of a subgroup consisting of PTMC patients without N1b revealed the number of central LN metastases as the only significant factor. Therefore, intraoperative examination for central LN metastasis may discriminate high or low risk group.
Carcinoma, Papillary/*pathology/radiotherapy/surgery ; Female ; Humans ; Iodine Radioisotopes/therapeutic use ; Lymph Node Excision ; Lymph Nodes/*pathology/surgery ; Lymphatic Metastasis/*pathology ; Male ; Middle Aged ; Neoplasm Recurrence, Local/surgery ; Prognosis ; Retrospective Studies ; Risk Factors ; Thyroid Neoplasms/*pathology/radiotherapy/surgery ; Thyroidectomy

PURPOSE: Regional lymph node (LN) metastases are detected in 57-85% of patients with papillary thyroid carcinoma (PTC) and are associated with increased tumor recurrence. However, the management of lymphatic disease in patients with PTC has been ongoing source of debate. We have prospectively assessed the usefulness and accuracy of sentinel LN (SLN) biopsy for the detection of LN metastases in patients with PTC on preoperative imaging using single photon emission computed tomography/computed tomography (SPECT/CT) and 99mTc phytate. METHODS: We prospectively assessed 39 patients with PTC who had risk factors for recurrence or with the necessity of intraoperative LN sampling for suspicious LN metastases on preoperative imaging from August 2010 to March 2011. The patients underwent preoperative lymphoscintigraphy and SPETC/CT and intraoperative SLN biopsy (SLNB). RESULTS: 99mTc lymphoscintigraphy and SPECT/CT localized SLN in 38 patients (97.4%), with the gamma probe identifying 2.15 mean SLNs in the lateral neck of the 39 patients. Skip metastasis was found in one patient, and lateral compartment LN metastasis in 17 (43.5%). The sensitivity, specificity, and accuracy of SLNB for lateral compartment LN metastasis were 88.2%, 100%, and 94.8%, respectively. SLNB was more accurate and useful for lateral than for central compartment LN metastasis. CONCLUSION: SPECT/CT improved SLN detection and anatomical localization compared with lymphoscintigraphy. SLNB in patients with risk factors for recurrence or the necessity of intraoperative LN sampling for suspected LN metastases on preoperative imaging was accurate in detecting LN metastases and may help in deciding whether to perform lateral compartment dissection in patients with PTC.
Biopsy ; Carcinoma ; Factor IX ; Humans ; Lymph Nodes ; Lymphatic Diseases ; Lymphoscintigraphy ; Neck ; Neoplasm Metastasis ; Nitriles ; Phytic Acid ; Prospective Studies ; Pyrethrins ; Recurrence ; Risk Factors ; Sensitivity and Specificity ; Sentinel Lymph Node Biopsy ; Thyroid Gland ; Thyroid Neoplasms ; Tomography, Emission-Computed, Single-Photon ; Tomography, X-Ray Computed