Purpose: Intraoperative neurophysiological monitoring (IONM) has been introduced in thyroid surgery to prevent injury of the recurrent laryngeal nerve (RLN). However, its effectiveness remains controversial in robotic thyroidectomy (RT). This study aimed to compare the surgical outcome of RT in patients with and without the application of IONM. Methods: This retrospective case-control study included 100 patients who underwent total thyroidectomy via robotic bilateral axillo-breast approach in a tertiary center. A study group of 50 patients who had IONM during RT was compared to a control group of 50 patients who underwent RT with nerve visualization alone. Results: The sex ratio (4:45 vs. 7:43, P = 0.538), mean age (39.3 ± 7.1 years vs. 37.5 ± 10.4 years, P = 0.304), and body mass index (23.1 ± 2.6 kg/m2 vs. 22.2 ± 3.9 kg/m2 , P = 0.215) were comparable between the IONM and control groups. Pathologic features including tumor size (0.8 cm vs. 0.9 cm, P = 0.283), extrathyroidal extension (58.0% vs. 24.0%, P = 0.316), lymph node metastasis (30% vs. 34%, P = 0.668), and number of lymph nodes (5.3 vs. 5.3, P = 0.668) showed no differences. There was no permanent RLN palsy, postoperative bleeding, and wound complications. Transient hypoparathyroidism was observed in 12 (24.0%) and 14 (28.0%), permanent hypoparathyroidism in 0 (0%) and 1 (2.0%), and transient RLN palsy was observed in 3 (6.0%) and 3 (6.0%), respectively. Conclusion We did not demonstrate a clear advantage of IONM in RT. Controversies regarding the effectiveness of IONM is not closed.

These guidelines aim to establish the standard practice for diagnosing and treating patients with differentiated thyroid cancer (DTC). Based on the Korean Thyroid Association (KTA) Guidelines on DTC management, the “Treatment of Advanced DTC” section was revised in 2024 and has been provided through this chapter. Especially, this chapter covers surgical and nonsurgical treatments for the local (previous surgery site) or regional (cervical lymph node metastasis) recurrences. After drafting the guidelines, it was finalized by collecting opinions from KTA members and related societies. Surgical resection is the preferred treatment for local or regional recurrence of advanced DTC. If surgical resection is not possible, nonsurgical resection treatment under ultrasonography guidance may be considered as an alternative treatment for local or regional recurrence of DTC. Furthermore, if residual lesions are suspected even after surgical resection or respiratory-digestive organ invasion, additional radioactive iodine and external radiation treatments are considered.

Pediatric differentiated thyroid cancers (DTCs), mostly papillary thyroid cancer (PTC, 80-90%), are diagnosed at more advanced stages with larger tumor sizes and higher rates of locoregional and/or lung metastasis. Despite the higher recurrence rates of pediatric cancers than of adult thyroid cancers, pediatric patients demonstrate a lower mortality rate and more favorable prognosis. Considering the more advanced stage at diagnosis in pediatric patients, preoperative evaluation is crucial to determine the extent of surgery required. Furthermore, if hereditary tumor syndrome is suspected, genetic testing is required. Recommendations for pediatric DTCs focus on the surgical principles, radioiodine therapy according to the postoperative risk level, treatment and follow-up of recurrent or persistent diseases, and treatment of patients with radioiodine-refractory PTCs on the basis of genetic drivers that are unique to pediatric patients.

Differentiated thyroid cancer demonstrates a wide range of clinical presentations, from very indolent cases to those with an aggressive prognosis. Therefore, diagnosing and treating each cancer appropriately based on its risk status is important. The Korean Thyroid Association (KTA) has provided and amended the clinical guidelines for thyroid cancer management since 2007. The main changes in this revised 2024 guideline include 1) individualization of surgical extent according to pathological tests and clinical findings, 2) application of active surveillance in low-risk papillary thyroid microcarcinoma, 3) indications for minimally invasive surgery, 4) adoption of World Health Organization pathological diagnostic criteria and definition of terminology in Korean, 5) update on literature evidence of recurrence risk for initial risk stratification, 6) addition of the role of molecular testing, 7) addition of definition of initial risk stratification and targeting thyroid stimulating hormone (TSH) concentrations according to ongoing risk stratification (ORS), 8) addition of treatment of perioperative hypoparathyroidism, 9) update on systemic chemotherapy, and 10) addition of treatment for pediatric patients with thyroid cancer.

The primary objective of initial treatment for thyroid cancer is minimizing treatment-related side effects and unnecessary interventions while improving patients’ overall and disease-specific survival rates, reducing the risk of disease persistence or recurrence, and conducting accurate staging and recurrence risk analysis. Appropriate surgical treatment is the most important requirement for this purpose, and additional treatments including radioactive iodine therapy and thyroid-stimulating hormone suppression therapy are performed depending on the patients’ staging and recurrence risk. Diagnostic surgery may be considered when repeated pathologic tests yield nondiagnostic results (Bethesda category 1) or atypia of unknown significance (Bethesda category 3), depending on clinical risk factors, nodule size, ultrasound findings, and patient preference. If a follicular neoplasm (Bethesda category 4) is diagnosed pathologically, surgery is the preferred option. For suspicious papillary carcinoma (suspicious for malignancy, Bethesda category 5), surgery is considered similar to a diagnosis of malignancy (Bethesda category 6). As for the extent of surgery, if the cancer is ≤1 cm in size and clinically free of extrathyroidal extension (ETE) (cT1a), without evidence of cervical lymph node (LN) metastasis (cN0), and without obvious reason to resect the contralateral lobe, a lobectomy can be performed. If the cancer is 1-2 cm in size, clinically free of ETE (cT1b), and without evidence of cervical LN metastasis (cN0), lobectomy is the preferred option. For patients with clinically evident ETE to major organs (cT4) or with cervical LN metastasis (cN1) or distant metastasis (M1), regardless of the cancer size, total thyroidectomy and complete cancer removal should be performed at the time of initial surgery. Active surveillance may be considered for adult patients diagnosed with low-risk thyroid papillary microcarcinoma. Endoscopic and robotic thyroidectomy may be performed for low-risk differentiated thyroid cancer when indicated, based on patient preference.

Conventional open thyroidectomy is a safe procedure, but it has the disadvantage of leaving noticeable scars on the neck. Bilateral axillo-breast approach (BABA) robotic thyroidectomy was developed as an alternative technique to remove thyroid glands without making incisions in the neck. In traditional BABA robotic thyroidectomy, dividing the isthmus is a routine step to improve the efficiency of the dissection during thyroid surgery. However, there are safety concerns when performing this procedure on patients with thyroid cancer located in the isthmus. We report a case of BABA robotic total thyroidectomy carried out without dividing the isthmus in a patient with isthmic papillary thyroid carcinoma. Our experience suggests that BABA robotic surgery can be a feasible and safe option for selected patients with isthmic papillary thyroid carcinoma.

Active surveillance (AS) of papillary thyroid microcarcinoma was first suggested by Dr. Akira Miyauchi at Kuma Hospital in 1993. Based on several subsequent evidences, AS was approved by the American Thyroid Association in 2015. AS is no longer an experimental treatment but has become an acceptable standard of care for patients with low-risk thyroid cancers. No molecular markers, such as BRAF mutations, have been identified to predict the prognosis of papillary thyroid cancer. However, future molecular studies may reveal the relationship between genetic mutations and thyroid cancer prognosis. AS involves closely monitoring thyroid cancer over time, instead of immediately treating it with surgery. Patients and medical doctors should consider these two options: observation or surgery.

Active surveillance (AS) of papillary thyroid microcarcinoma was first suggested by Dr. Akira Miyauchi at Kuma Hospital in 1993. Based on several subsequent evidences, AS was approved by the American Thyroid Association in 2015. AS is no longer an experimental treatment but has become an acceptable standard of care for patients with low-risk thyroid cancers. No molecular markers, such as BRAF mutations, have been identified to predict the prognosis of papillary thyroid cancer. However, future molecular studies may reveal the relationship between genetic mutations and thyroid cancer prognosis. AS involves closely monitoring thyroid cancer over time, instead of immediately treating it with surgery. Patients and medical doctors should consider these two options: observation or surgery.

In the brain, a reduction in extracellular osmolality causes water-influx and swelling, which subsequently triggers Cl⁻- and osmolytes-efflux via volume-regulated anion channel (VRAC). Although LRRC8 family has been recently proposed as the pore-forming VRAC which is activated by low cytoplasmic ionic strength but not by swelling, the molecular identity of the pore-forming swelling-dependent VRAC (VRAC(swell)) remains unclear. Here we identify and characterize Tweety-homologs (TTYH1, TTYH2, TTYH3) as the major VRAC(swell) in astrocytes. Gene-silencing of all Ttyh1/2/3 eliminated hypo-osmotic-solution-induced Cl⁻ conductance (I(Cl,swell)) in cultured and hippocampal astrocytes. When heterologously expressed in HEK293T or CHO-K1 cells, each TTYH isoform showed a significant I(Cl,swell) with similar aquaporin-4 dependency, pharmacological properties and glutamate permeability as I(Cl,swell) observed in native astrocytes. Mutagenesis-based structure-activity analysis revealed that positively charged arginine residue at 165 in TTYH1 and 164 in TTYH2 is critical for the formation of the channel-pore. Our results demonstrate that TTYH family confers the bona fide VRAC(swell) in the brain.
Arginine ; Astrocytes ; Brain ; Cytoplasm ; Glutamic Acid ; Humans ; Osmolar Concentration ; Permeability

PURPOSE: Routine supplementation of high-dose calcium significantly decreased the risk of postoperative symptomatic hypocalcemia after thyroidectomy. However, there is an ongoing debate about whether the same results can be achieved with low-dose calcium supplementation. METHODS: Patients (n = 138) who underwent total thyroidectomy for thyroid cancer were 1:1 randomly assigned to receive oral supplements of 1,500 mg/day elemental calcium and 1,000 IU/day cholecalciferol for 2 weeks or no supplementation. Primary objective was to compare the incidence of symptomatic hypocalcemia for 3 days after total thyroidectomy. Secondary objective was to find the predictors for postoperative hypocalcemia in patients with thyroid cancer. RESULTS: Sixty-five patients in the calcium group and 69 patients in the control group were finally analyzed. The incidence of symptomatic hypocalcemia showed no difference between the calcium and control group (32.3% vs. 21.7%, P = 0.168). The total dosage of intravenous calcium (593.4 ± 267.1 mg vs. 731.6 ± 622.7 mg, P = 0.430) administered to patients with symptomatic hypocalcemia was also comparable between groups. In a multivariate analysis, parathyroid hormone level of 13 pg/mL at postoperative day 1 was only predictive for symptomatic hypocalcemia, and its incidence was 20.9 times (95% confidence interval, 6.8–64.5) higher in patients with parathyroid hormone <13 pg/mL. Other factors did not predict the development of hypocalcemia, including clinicopathological features and routine supplementation of low-dose calcium. CONCLUSION: Routine low-dose calcium supplementation did not reduce the risk of postoperative hypocalcemia. Patients who may benefit from calcium supplementation should be carefully selected.
Calcium ; Cholecalciferol ; Humans ; Hypocalcemia ; Hypoparathyroidism ; Incidence ; Multivariate Analysis ; Parathyroid Hormone ; Prospective Studies ; Thyroid Neoplasms ; Thyroidectomy