Abstract:For convenient and simple operation and excellent cosmetic results, endoscopic thyroid surgery via bilateral areolar approach has gradually become the first choice of endoscopic procedure for thyroid lobectomy. However, the levels of ability and proficiency vary widely among hospitals and surgical teams carrying out endoscopic thyroid surgery. So, how to promote a standardized endoscopic thyroidectomy is an urgent problem to be solved at present. Here, the authors, taking the areolar approach as an example, introduce the procedure of endoscopic lobectomy used by the surgical team led by WANG Ping in the Second Affiliated Hospital of Zhejiang University. For convenience of memorization, the procedure is divided into seven steps and named as Wang’s seven-step method.

Abstract:In recent years, the rapid increase in incidence of papillary thyroid microcarcinoma (PTMC) worldwide has spurred great attention and even disputes in its diagnosis and treatment. At present, two strategies for diagnosis and treatment of PTMC have been proposed by some scholars at home and abroad: one is “overdiagnosis and overtreatment”, and the other is “active surveillance and delayed intervention”. However, by taking an integrated account of the characteristics of PTMC, patients’ preferences, and medical circumstances and resources, “active surveillance and opportunistic intervention” is considered to be the best strategy to date.

Abstract:High-resolution ultrasound has become the first line imaging modality to determine the nature, size and location of suspicious thyroid nodules due to high sensitivity and excellent specificity. A professional and accurate ultrasound examination is the premise for realizing standardized, individualized and precise diagnosis and treatment of thyroid cancer. Surgeons not only have the superiority in learning ultrasound examination skills, but also can expand its clinical application value based on their clinical experience. Through performing ultrasound examination, surgeons could make better preoperative staging and risk stratification of the thyroid cancer, and more individualized treatment plan, and meanwhile, could also enhance their professional skills, and provide timely, convenient and effective postoperative follow-up, and thereby improve patients’ compliance. With the development of ultrasonics, molecular diagnostic techniques and artificial intelligence technologies, the portable ultrasound machine and mobilation advancements in the future will accelerate transition of traditional thyroid surgery towards precise thyroid surgery.

Abstract:Objective: To investigate the clinicopathologic and neck metastasis features of multifocal papillary thyroid cancer (PTC). Methods: The clinical data of 323 patients undergoing surgical treatment in Department of Thyroid Surgery, the First Affiliated Hospital of Zhengzhou University from June 2016 to October 2016, who had pathologically confirmed PTC were retrospectively analyzed. Of the patients, 148 cases had multifocal PTC and 175 cases were unifocal PTC. Results: No significant difference was seen in age, gender and maximal tumor diameter between patients with multifocal PTC and unifocal PTC (all P>0.05), but the former showed higher incidence of central neck metastasis (P<0.001), lateral neck metastasis (P=0.028), and extrathyroidal extension (P<0.001) than those in the latter. Among patients with multifocal PTC, the incidence of central neck metastasis (P=0.010), lateral neck metastasis (P=0.018) and extrathyroidal extension (P=0.020) in cases with 3 or more lesions were significantly increased compared with cases with 2 lesions. Multivariate analysis showed that the maximal tumor diameter (P=0.005) and tumor number (P=0.006) were independent risk factors for central neck metastasis in multifocal PTC. Conclusion: Compared to unifocal PTC, multifocal PTC has relatively higher invasiveness, is more likely to develop metastasis and invasion, for which total thyroidectomy with central compartment neck dissection is recommended as the standard treatment, and lateral neck dissection should be strongly considered in those with lateral neck lymph node enlargement.

Abstract:Objective: To investigate the clinical characteristics of papillary thyroid microcarcinoma (PTMC) and its diagnosis and treatment strategies. Methods: The clinical and pathologic data of 47 patients with PTMC that was confirmed by surgical and pathological findings from June 2011 to May 2016 were retrospectively analyzed. Results: Of the 47 patients, 9 cases were male and 38 cases were female, with an average age of (46.3±12.1) years and average disease course of (12.4±23.7) months; all cases underwent preoperative ultrasound examination, and 14 cases underwent ultrasound-guided fine-needle aspiration biopsy (FNA) by which PTMC was diagnosed in 11 cases (78.6%); 13 cases underwent total resection of the affected lobe, 3 cases underwent total resection of affected lobe plus subtotal resection of the contralateral lobe, and 31 cases underwent total thyroidectomy; 14 cases underwent central neck dissection and 15 cases underwent central plus lateral neck dissection. The average axis diameter of the tumors was (0.68±0.23) cm, and 21 patients (44.7%) had multiple lesions, of whom, 14 cases (29.8%) had bilateral thyroid multiple lesions. Twenty-nine patients underwent cervical lymph node dissection and 48.3% (14/29) had central lymph node metastasis. The incidence of lateral lymph node metastasis was 53.3% (8/15). Univariate analysis showed that capsular invasion was significantly associated with lymph node metastasis (P=0.035). Postoperative complications occurred in 8 patients, including transient hypoparathyroidism in 5 cases, and incisional fluid collections and transient recurrent laryngeal nerve injury and superior laryngeal nerve injury in one case each. Conclusion: Thyroid surgeons should be familiar with ultrasound features of thyroid carcinoma, and expansion of the indications to FNA is not recommended. For patients with multiple nodules indicated by preoperative ultrasound or suspected to have multiple nodules during intraoperative exploration, or patients who present with high-risk factors, total thyroidectomy is recommended. Prophylactic central group lymph node dissection with intraoperative frozen pathology diagnosis is essential for surgeons to design a personalized surgical plan and postoperative therapy.

Abstract:Objective: To investigate the application value of meticulous capsular dissection in thyroidectomy for differentiated thyroid carcinoma (DTC). Methods: The data of 75 patients with DTC undergoing total thyroidectomy with central neck dissection from March 2011 to March 2015 were reviewed. Meticulous capsular dissection was applied in all patients for identification and preservation in situ of the parathyroid glands, and timely intraoperative parathyroid autotransplantation was performed in those with severe ischemic or inadvertently dissected parathyroid glands. Results: Of the 75 patients, all parathyroid glands were intraoperatively identified and preserved in situ in 46 cases, and 2 or 3 parathyroid glands were preserved in situ in the remaining cases. Twelve hours after operation, some patients had mild numbness in the lip and hands or feet, or slight convulsions, but no dyspnea, shock or other serious complications occurred in any of them. The serum calcium in 18 patients was lower than 2.0 mmol/L on one month after operation, the serum calcium in 11 patients was less than 2.0 mmol/L on 2 to 3 months after operation and the serum calcium in all patients was higher than 2.0 mmol/L on 4 to 6 months after operation. Postoperative follow-up was conducted for 16 to 18 months, and in all of them, the serum calcium was higher than 2.0 mmol/L, and no clinical symptoms of hypocalcemia were noted. Conclusion: Using meticulous capsular dissection in thyroidectomy for DTC patients can help accurately identify and as maximally as possible preserve the parathyroid glands in situ.

Abstract:Objective: To investigate the diagnosis and treatment of bilateral chylothorax following neck dissection for thyroid cancer. Methods: The clinical data of two patients with bilateral chylothorax after neck dissection for thyroid cancer were retrospectively analyzed, and combined with related literature review. Results: Both patients underwent neck dissection for papillary thyroid carcinoma and no lymphorrhea was observed in either of them during operation. On the fourth postoperative day, both patients developed shortness of breath and dyspnea, and were found to have bilateral hydrothorax by chest X-ray examination and milky chylous fluid was drained with bilateral closed drainage of pleural cavity, and then were diagnosed as bilateral chylothorax. After aggressive treatment such as fasting and octreotide administration, the drainage volumes of the two patients were gradually reduced, and their drainage tubes were removed after thoracic fluid collections disappeared in review X-ray examination. Conclusion: Bilateral chylothorax is an extremely rare complication after neck dissection for thyroid cancer, and aggressive conservative treatment is safe and effective after early detection.

Abstract:Objective: To investigate the expressions of tumor microenvironment-associated factors IL-6, IL-10 and chemokine receptor 7 (CXCR7) in papillary thyroid carcinoma and their significance. Methods: The expressions of IL-6, IL-10 and CXCR7 in 50 specimens of papillary thyroid carcinoma tissue and 20 specimens of nodular goiter tissue were detected by immunohistochemical staining. The expression differences of the three factors between the two types of tissues were compared, and the relations of the three factors with the clinicopathologic factors of papillary thyroid carcinoma were analyzed. Results: The positive expression rates of IL-6, IL-10 and CXCR7 in papillary thyroid carcinoma tissue were all significantly higher than those in nodular goiter tissue (62.0% vs. 30.0%, 52.0% vs. 20.0% and 66.0% vs. 35.0%, all P<0.05). In patients with papillary thyroid carcinoma, the high expression of IL-6 or IL-10 was associated with tumor capsular invasion (both P<0.05), while high expression of CXCR7 was associated with lymphatic metastasis (P<0.05). Conclusion: The expressions of tumor microenvironment-associated factors IL-6, IL-10 and CXCR7 are increased in papillary thyroid carcinoma tissue, and their expression levels can be used as reference designators for estimating the invasion and metastasis of papillary thyroid carcinoma.

Abstract:Objective: To investigate to the effect of vitamin C (VitC) on enhancing the sensitivity of breast cancer cells to paclitaxel (PTX) chemotherapy and the mechanism. Methods: In primary cultured human breast cancer cells after exposure to VitC alone or PTX alone or their combination, the proliferation, apoptosis and expressions of caspase-3 and Bcl-2MTS were determined by MTS assay, flow cytometry and Western blot analysis, respectively. Results: In breast cancer cells, the IC50 of VitC alone was 2.5 mmol/L and PTX alone was 8.6 nmol/L, while IC50 of PTX combined with 1 mmol/L VitC was 2.8 nmol/L. VitC alone had certain apoptosis inducing effect on breast cancer cells, and the apoptosis inducing effect of PTX combined with VitC was significantly greater than that of PTX alone, which was also increased with increase of the concentration of VitC (all P<0.05). The caspase-3 expression was increased and Bcl-2 expression was decreased significantly after exposure of PTX alone, and these effects were enhanced by combination with VitC, and increased with the increase of the concentration of VitC added (all P<0.05). Conclusion: VitC can enhance the sensitivity of breast cancer cells to PTX chemotherapy, and this action may be related to its further increase caspase-3 and decrease Bcl-2 expressions.

Abstract:Objective: To investigate the influences of hepatitis C virus (HCV) proteins NS3, Core and NS5A on RASSF2 mRNA expression and methylation status of RASSF2A promoter in hepatic cells. Methods: The RASSF2 mRNA expressions in hepatic cells respectively transfected with NS3-, Core- and NS5A-expression plasmids (NS3/QSG7701, Core/QSG7701 and NS5A/QSG7701) as well as normal hepatic cell line L02 were determined by RT-PCR method. The methylation statuses of RASSF2A promoter in NS3/QSG7701, Core/QSG7701 and NS5A/QSG7701 cells were examined by methylation-specific PCR, and the changes in their RASSF2 mRNA expressions and biological behaviors after treatment with demethylation agent 5-aza-dC were observed. Results: The RASSF2 mRNA expressions were significantly decreased in all NS3/QSG7701, Core/QSG7701 and NS5A/QSG7701 cells compared with L02 cells (all P<0.05), and the RASSF2A promoters were fully methylated in all the three types of cells. After 5-aza-dC treatment, the RASSF2 mRNA expression was upregulated in NS3/QSG7701 and Core/QSG7701 cells (both P<0.05), but did not change in NS5A/QSG7701 cells (P>0.05); the proliferation rate was decreased and apoptosis rate was increased in NS3/QSG7701 and Core/QSG7701 cells5-aza-dC treatment (both P<0.05). Conclusion: NS3, Core and NS5A can reduce RASSF2 expression through RASSF2A promoter methylation and also through other mechanism by NS5A. This effect may probably contribute to the carcinogenesis of HCV-associated hepatocellular carcinoma.

Abstract:Objective: To investigate the inhibitory effect of apatinib-loaded nanomicelles on human umbilical vein endothelial cells (HUVECs) as well as its release pattern and safety. Methods: The release rate and use safety of apatinib-loaded nanomicelles was determined by ultraviolet spectrophotometry method and hemolytic assay, respectively. And then, the inhibitory effect of apatinib-loaded nanomicelles on HUVECs was tested by CCK-8 assay, migration assay and tube formation assay, respectively. Results: The apatinib-loaded nanomicelles showed a transient immediate-release (2 h release rate reached 20.5%) and then a slow release (72 h release rate was 62.9%), and the results of hemolytic assay were negative. The proliferation of HUVECs was significantly inhibited by either apatinib-loaded nanomicelles or free apatinib in a concentration- and time-dependent manner (all P<0.05); the inhibition rate of apatinib-loaded nanomicelles on HUVECs was lower than those of free apatinib within 48 h (48 h IC50: 1.385 μmol/L vs. 0.768 μmol/L, P=0.012), but it surpassed that of free apatinib with time up to 72 h (63.34% vs. 59.70%, P=0.005). The migration and tube formation of HUVECs were significantly suppressed by both apatinib-loaded nanomicelles and free apatinib in a concentration- and releasing time-dependent manner, and the inhibitory effects of apatinib-loaded nanomicelles with 3-d release on migration and tube formation of HUVECs were significantly greater than those of free apatinib (both P<0.05). Conclusion: The apatinib-loaded nanomicelles have good safety and sustained release property. Nanoencapsulation can enhance the inhibitory effect of apatinib on HUVECs and extend its action time window.

Abstract:Objective: To evaluate the efficacy and safety of using oncoplastic techniques in breast-conserving surgery for early breast cancer. Methods: The clinical data of 139 patients with stage I–II breast cancer undergoing oncoplastic breast-conserving surgery from August 2011 to August 2016 were retrospectively analyzed. The long-term outcomes of these patients were also compared with those of 1 271 patients with stage I–II breast cancer undergoing modified radical mastectomy during the same period. Results: Of the 139 patients, 133 cases underwent breast-conserving surgery with volume displacement technique (local breast tissue flap advancement reconstruction), of whom 45 cases had synchronous contralateral reduction mammoplasty, and 6 cases received breast-conserving surgery with volume replacement technique (autologous tissue transplantation reconstruction); 78 cases underwent sentinel lymph node biopsy and 61 cases received axillary lymph node dissection. The weight of resected tissue ranged from 30 to 187 g with average weight of 69.5 g. The cosmetic results were determined as excellent in 79 patients, good in 47 patients, ordinary in 10 patients and poor in 3 patients. Postoperative follow-up was conducted for 3 to 63 months with an average of 28.2 months. In patients undergoing oncoplastic breast-conserving surgery, the 2-year local recurrence rate (4.3% vs. 4.1%), overall survival rate (95.7% vs. 95.5%) and disease free survival rate (85.6% vs. 85.3%) showed no significant difference with those in patients subjected to modified radical mastectomy (all P>0.05). Conclusion: Breast-conserving surgery with oncoplastic techniques for early breast cancer offers good oncological safety, satisfactory cosmetic results and long-term outcome similar to modified radical mastectomy. Appropriate selection of patients and oncoplastic procedures are critical for achieving optimal postoperative results in oncoplastic breast-conserving surgery.

Abstract:Objective: To investigate the clinical efficacy of regular treatment plus air wave pressure therapy for erysipelas of the upper limb on the operated side following modified radical mastectomy for breast cancer. Methods: The data of 18 breast cancer patients undergoing modified radical mastectomy who developed postoperative erysipelas of the upper limb on the operated side in the Fourth Affiliated Hospital of China Medical University from January 2013 to June 2016 were retrospectively analyzed. Of the patients, 10 patients underwent regular treatment for erysipelas (regular treatment group), and 8 cases received air wave pressure therapy on the basis of regular treatment (combined treatment group). The main clinical variables between the two groups of patients were compared. Results: There was no significant difference between the two groups of patients in terms of age, proportion of radiotherapy cases, skin damage, body mass index, underlying diseases and severity of edema of the affected upper limb (all P>0.005). The conditions of all the 18 patients were significantly improved after treatment, but the average length of hospital stay in combined treatment group was significantly shortened compared with regular treatment group (10.9 d vs. 14.5 d, P=0.001). Conclusion: Combined air wave pressure therapy can remarkably improve the treatment effect on upper limb erysipelas following modified radical mastectomy and effectively reduce the treatment time.

Abstract:Objective: To investigate the clinical efficacy of using local tumescent anesthesia technique in minimally invasive Mammotome rotation cutting for multiple solid breast lesions. Methods: Ninety-eight patients with multiple solid breast lesions undergoing minimally invasive Mammotome rotation cutting from June 2010 to July 2012 were randomly enrolled. Of the patients, 49 cases underwent surgery under traditional local infiltration anesthesia (control group), and the other 49 cases underwent surgery with local tumescent technique (observation group). The main clinical variables between the two groups of patients were compared. Results: There was no difference in age, tumor size and tumor number between the two groups of patients (all P>0.05). In observation group compared with control group, the average time for anesthesia (16.10 min vs. 31.41 min) and operative time (39.47 min vs. 62.53 min) were shortened, the anesthestic dose (0.20 mg vs. 0.31 mg) was reduced, the good anesthetic effect rate (96% vs. 82%) was increased, and incidence of anesthesia adverse reactions (0% vs. 12%) as well as incidence of operative complications (4% vs. 18%) were decreased. All the differences had statistical significance (all P<0.05). Conclusion: Using local tumescent anesthesia technique in minimally invasive Mammotome rotation cutting for multiple solid breast lesions is safe and effective, with significant clinical efficacy. It is recommended to be used in clinical practice.

Abstract:Objective: To investigate the feasibility of using primary gross tumor volume (GTV) for predicting the pathologic complete response (pCR) to neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced rectal cancer (LARC). Methods: The data of 107 LARC patients undergoing nCRT followed by radical surgery in Department of Gastrointestinal Surgery, Xiangya Hospital of Central South University between March 2009 and December 2015 were reviewed. The factors for predicting pCR in LARC patients after nCRT were determined. The expressions of CD133 in the tumor specimens of these patients were measured by immunohistochemical staining, and then the relationship between primary GTV and rectal cancer stem cells was analyzed. Results: In the 107 LARC patients, pCR was achieved in 25 cases (23.36%). The primary GTV was positively correlated with the length along the longitudinal axis of the bowel (r=0.580, P<0.001) and maximal diameter (r=0.608, P<0.001) of the primary tumor, while the significant differences between pCR patients and non-pCR patients were only found in primary GTV (P=0.024), serum CEA level before nCRT (P=0.020), and multiple-drug combined chemotherapy (P=0.05). The optimal cut-off values for primary GTV to estimate the response of tumor was 70.29 cm3. The results of Logistic regression analysis showed that the small primary GTV (<70 cm3) (P=0.019) and multiple-drug combined chemotherapy (P=0.032) were independent promotion factors for LARC patients to achieve pCR after nCRT. The CD133 expression in the tumor tissues of patients with large primary GTV (≥70 cm3) was significantly higher than that in patients with small primary GTV (<70 cm3) (P=0.017). Conclusion: Primary GTV can be used as an independent predictive factor for pCR in LARC patients after nCRT. Big primary GTV is associated with low pCR rate, which is probably due to the bigger the primary GTV, the larger the amount of cancer stem cells in the tumor.

Abstract:Objective: To extract and summarize the anatomic variations of the celiac axis (CA), so as to provide evidence and guidance for clinical practice. Methods: The imaging data of patients who underwent abdominal multislice spiral CT angiography from April 2016 to August 2016 were retrospectively analyzed. The origins and patterns of the running course of CA and its branches were observed, and then were categorized and counted. Results: A total of 425 patients were enrolled, including 280 males and 145 females. CA was classified into 5 main types. Two hundred and forty patients (56.5%) were identified as type I that included type Ia in 168 cases, type Ib in 67 cases and type Ic in 5 cases; 159 patients (37.4%) belonged to type II; type III was found in 23 patients (5.4%), of whom, 9 cases were type IIIa and 14 cases were type IIIb; 2 patients (0.5%) were categorized as type IV, with 1 male and 1 female each; type V was diagnosed in 1 patent (0.2%). Conclusion: CA has high variation rate, and knowledge of its variations is especially important for surgeons and radiologists.

Abstract:Whether thyroid-stimulating hormone (TSH) suppression therapy may change bone mineral density and cause osteoporosis signs in some patients with differentiated thyroid carcinoma (DTC) remains controversial. Here, the authors present the current research progress of DTC TSH suppression therapy associated changes in bone metabolism from the viewpoints of both experimental and clinical studies.

Abstract:

Thyroglobulin (Tg), a large glycoprotein molecular synthesized and secreted by thyroid follicular cells, serves as a substrate for the synthesis of thyroid hormones. Tg can also be produced with varying levels by differentiated thyroid carcinoma (DTC) originating from thyroid follicular cells. As a specific tumor marker for DTC, Tg has been used in DTC patients for post-surgical risk stratification, efficacy evaluation, long-term follow-up surveillance and prognostic estimation. There are many practical issues in using serum Tg value to assess DTC disease, because of its heterogeneous molecular structure and the technical restriction in its blood value detection as well as the interference of Tg autoantibodies. Even so, the ultrasensitive detection methods developed in recent years further increased the clinical applicability of Tg. Here, the authors provide a brief overview of the research progress of Tg and some important points in its clinical applications.

Abstract:With the continuous promotion of endoscopic techniques and concept of minimally invasive surgery at home and abroad, endoscopic thyroid surgery has seen the emergence of a variety of operation methods and rapid development. In this paper, the authors address the usually used approaches and methods for creating surgical space as well as some new technologies and concepts in endoscopic thyroid surgery.

Abstract:Better exposure and protection of recurrent laryngeal nerve (RLN) are critical to ensure the quality and safety of thyroid surgery. The temporary or permanent RLN injury during or after operation caused by anatomical variations of the RLN and iatrogenic damage may affect the patients’ quality of life and the prognosis of the disease. Here, the authors, based on literature review and experiences of clinical practice, address the anatomical variation features of the RLN and the indications and surgical techniques for five different exposure methods of the RLN.