Volume 32,Issue 5,2023 Table of Contents

1 Hunan expert consensus on prevention and management of postoperative bleeding after thyroid surgery

2023, 32(5):627-639. DOI: 10.7659/j.issn.1005-6947.2023.05.001

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In recent years, the incidence of thyroid tumors has rapidly increased, leading to a corresponding rise in the number of thyroid surgeries performed annually. Postoperative bleeding and resultant airway compression are the most dangerous complications after thyroid surgery, and in severe cases, can result in death, posing potential medical disputes. Providing necessary professional training is crucial to enhance early recognition of postoperative bleeding and airway compression after thyroid surgery. Timely and appropriate management of postoperative bleeding and airway compression can prevent further complications and irreversible consequences. In addition, the management of complications related to postoperative bleeding after thyroid surgery requires a multidisciplinary team (MDT) involving surgeons, anesthesiologists, and nursing staff. Based on extensive clinical experience and literature review, and grounded on evidence-based medicine, experts from relevant fields in Hunan province have developed a "Consensus on the Prevention and Management of Postoperative Bleeding after Thyroid Surgery", so as to improve surgical safety, reduce the incidence of postoperative bleeding, and facilitate timely detection and management.

2 Current status and prospects of transoral endoscopic thyroid surgery

MA Junjie , WANG Ping

2023, 32(5):640-647. DOI: 10.7659/j.issn.1005-6947.2023.05.002

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Transoral endoscopic thyroidectomy (TOET) is a type of natural orifice transluminal endoscopic surgery (NOTES). In 2008, Witzel et al. first attempted transoral endoscopic thyroidectomy through the oral floor in fresh cadavers and live pigs. Professor Wang Cunchuan in China was the first to propose the three-port transoral endoscopic thyroidectomy vestibular approach (TOETVA) internationally. Currently, this is the most widely used transoral endoscopic approach for thyroid surgery, with the main advantages of minimal damage to the oral floor structures and greater instrument maneuverability. It leaves no visible scars on the skin surface, meets the dual requirements of disease cure and aesthetic appearance, and ensures privacy protection. TOETVA provides a top-down view, which, due to its natural visual advantage, resolves the problem of low-level lymph node dissection in the central region. Therefore, TOETVA is the preferred surgical procedure for cases of differentiated thyroid cancer with central lymph node metastasis. Since its introduction in 2013, TOETVA has been initially developed in China, and multiple centers started attempting it in 2015. To date, there are already hundreds of institutions in China capable of performing this procedure. The technical key points and challenges of TOETVA mainly include the establishment and maintenance of space, exposure and protection of the recurrent laryngeal nerve, identification and preservation of the parathyroid glands, and lymph node dissection. Compared to the transthoracic approach, transoral endoscopic thyroid surgery has a steeper learning curve, typically requiring 40-50 cases to overcome. In comparison to open surgery and other scarless endoscopic thyroidectomy approaches, in addition to common complications such as bleeding, nerve injury, parathyroid injury, and flap injury, transoral endoscopic thyroid surgery has the following special complications: mental nerve injury, infection, CO₂ gas embolism, pleural injury, and abnormal functional reactions in the mandibular region, among others. TOETVA has shown good tumor control and aesthetic outcomes, experiencing rapid development over the past decade. As part of the NOTES surgical system, it represents the trend of endoscopic and minimally invasive surgery. The future focus is on scientific application and promotion of TOETVA technology, with strict adherence to surgical indications being of utmost importance. Only by adhering to the basic principles of "treating the disease first, preserving function second, and considering aesthetics third" can TOETVA be scientifically and standardizedly promoted. Additionally, teaching hospitals should take the lead in actively promoting the dissemination of guidelines and consensus, while continually demonstrating surgical procedures in clinical practice. Expanding indications, improving surgical techniques, and developing new technologies are the hotspots of future research in TOETVA. The surgical indications for TOETVA are not absolute, and as the operator's skills improve, the surgical difficulty can gradually increase. However, it should be noted that any procedure beyond the current guidelines and expert consensus is considered unconventional surgery. Currently, the expansion of indications for TOETVA is mainly represented by lateral neck dissection, but dissection of level Ⅱ lymph nodes remains challenging. Therefore, there is controversy regarding whether TOETVA can achieve a radical effect with lateral neck dissection. This article provides an overview of the current status and prospects of this approach based on domestic and international literature and our center's relevant experience.

3 Current situation and considerations of the interpretation of clinical thyroid cancer genetic testing reports

PENG Ying , CHENG Ruochuan

2023, 32(5):648-655. DOI: 10.7659/j.issn.1005-6947.2023.05.003

[Abstract](407) [HTML](1354) [PDF 792.50 K](1586)

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Genomic sequencing is the fundamental approach for achieving precision medicine in cancer treatment. It assists in tumor diagnosis, prognosis assessment, and guidance for targeted drug therapy. In recent years, genomic sequencing technology has been widely applied in the clinical diagnosis and treatment of thyroid cancer. However, as of now, different medical centers vary in their control over the indications for genomic sequencing, the level of report interpretation, and the reliability of the results from various sequencing platforms. This article aims to analyze the current status and issues of genomic testing in the diagnosis and treatment of thyroid cancer, combining the authors' personal clinical experience, to discuss the uniqueness and value of genomic testing in the entire management process of thyroid cancer.

4 Capacity building and development trends of the multidisciplinary integrated treatment model for breast cancer

WANG Jiani , OU Kaiping , LIU Jiaqi , CHE Shu'nan , CHEN Siye , GUO Changyuan , MA Fei

2023, 32(5):656-664. DOI: 10.7659/j.issn.1005-6947.2023.05.004

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Breast cancer is the most prevalent malignant tumor globally and poses a major threat to women's health. With the vigorous development of surgical treatment, medical systemic therapy, radiation therapy, and other interdisciplinary approaches, the treatment of breast cancer has shifted from a "disease-oriented" model to a "patient-centered" multidisciplinary comprehensive treatment (MDT) model. Promoting the capacity building of breast cancer MDT, optimizing the allocation of medical resources, and achieving skill enhancement and individualized precision diagnosis and treatment based on a multidisciplinary diagnostic and therapeutic mindset are the future development trends. As the concept of MDT continues to expand and evolve, patients' treatment strategies are constantly being optimized, driving the continuous improvement of the level of breast cancer diagnosis and treatment in China towards the highest standards.

5 Application value of gasless endoscopic thyroid surgery via axillary approach in middle-aged and elderly patients

YANG Peng , ZHU Xiaochao , CHEN Zhifeng , XU Nan'gan , TIAN Mingming , HUANG Chao , LIU Li , WANG Fuchao , GUAN Xiaoqing , SHE Xinyuan , WANG Qianyu , ZHENG Xiangxin

2023, 32(5):665-672. DOI: 10.7659/j.issn.1005-6947.2023.05.005

[Abstract](787) [HTML](618) [PDF 692.38 K](1218)

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Background and Aims In recent years, with the continuous advancement of minimally invasive technology and the increasing demand for quality of life, endoscopic thyroid surgery has gradually become popular and is particularly favored by young female patients. For middle-aged and elderly patients, open surgery still dominates in clinical practice, and many patients may experience postoperative complications such as flap sagging, swallowing difficulties, and foreign body sensation, which can significantly impact their daily lives. The gasless transaxillary endoscopic thyroid surgery technique utilizes the natural gaps between neck muscles to create a working space, allowing for exposure and surgical manipulation of the thyroid gland beneath the deep surface of the sternocleidomastoid muscle. This approach has minimal impact on neck function and does not require CO₂, resulting in reduced effects on the cardiovascular and respiratory systems. This study aims to explore the efficacy and safety of gasless transaxillary endoscopic thyroid surgery in middle-aged and elderly patients, providing a reference for its application in this patient population.Methods The clinical data of 56 middle-aged and elderly patients with thyroid cancer admitted to the First People's Hospital of Suqian from January 2021 to June 2022 were retrospectively analyzed. Among them, 26 cases underwent gasless transaxillary endoscopic thyroid surgery (observation group), and 30 cases underwent traditional open surgery (control group). The surgical variables, pain status, neck injury index, swallowing disorder index, complications, and prognosis were compared between the two groups of patients.Results All 56 patients successfully underwent the surgery. The observation group had longer operative time and higher postoperative drainage volume compared to the control group (both P<0.05). There were no statistically significant differences between the two groups in terms of intraoperative bleeding, dyspnea, hoarseness, numbness in the extremities, coughing while drinking, subcutaneous hematoma, the number of resected central lymph nodes, and length of hospital stay (all P>0.05). The incidence rates of postoperative complications such as neck flap sagging, adhesions, swallowing linkage, pain and numbness, and foreign body sensation were significantly lower in the observation group than those in the control group (all P<0.05). Follow-up was conducted for 6 to 24 months in both groups, and no cases of recurrence or metastasis were observed.Conclusion Gasless transaxillary endoscopic thyroid surgery demonstrates good efficacy and safety in middle-aged and elderly patients with thyroid cancer. It significantly reduces postoperative complications such as neck skin sagging, adhesions, swallowing linkage, pain and numbness, and foreign body sensation. Furthermore, it improves the quality of life for patients. Therefore, this surgical technique has certain clinical application value.

6 Factors and predictive model construction for lymph nodes posterior to right recurrent laryngeal nerve metastasis in cN0-stage papillary thyroid carcinoma

DONG Meng , HONG Chenchen , NIE Xinyue , LIAO Shichong , YAO Feng

2023, 32(5):673-681. DOI: 10.7659/j.issn.1005-6947.2023.05.006

[Abstract](566) [HTML](620) [PDF 1.01 M](1034)

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Background and Aims Patients with papillary thyroid carcinoma (PTC) often present with central lymph node metastasis, and unilateral/bilateral thyroid lobectomy combined with central lymph node dissection (CLND) is the primary treatment approach. However, due to anatomical variations, there is still controversy regarding whether dissection of the lymph nodes posterior to right recurrent laryngeal nerve (LN-prRLN) should be performed in PTC patients with clinically negative neck lymph nodes (cN0). Currently, there is limited research on the factors influencing LN-prRLN metastasis in cN0-stage PTC patients, and there is a lack of personalized quantitative prediction tools for assessing the risk of LN-prRLN metastasis. Therefore, this study was conducted to explore the factors for LN-prRLN metastasis in cN0-stage PTC patients and develop an individualized prediction model to provide decision-making guidance for LN-prRLN dissection.Methods The clinicopathologic data of 410 patients with papillary thyroid cancer who underwent thyroid surgery at Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University from June 2019 to December 2022 were retrospectively analyzed. The patients were randomly divided into a training group and a validation group in a 7∶3 ratio. Based on the postoperative pathological results of LN-prRLN metastasis, the patients were categorized into LN-prRLN positive and LN-prRLN negative groups. Data including patient age, sex, BMI, thyroid ultrasound results, thyroid function, postoperative pathology, and lymph node metastasis were collected. Univariate analysis and multivariate Logistic regression analysis were performed to determine independent risk factors for LN-prRLN metastasis in cN0-stage PTC. A visualized prediction nomogram model was constructed based on the selected independent risk factors. The model's performance was validated by plotting the ROC curve to calculate the area under the curve (AUC), calibration curves and decision curve analysis.Results In comparison between the LN-prRLN positive group and the LN-prRLN negative group, univariate analysis revealed statistically significant differences in tumor size (P<0.001), tumor multifocality (P=0.021), capsular/extrathyroidal invasion (P=0.011), and positive lymph nodes in the right neck level VIA (P<0.001). The results of multivariate Logistic regression analysis showed that larger tumor size (P=0.037), tumor multifocality (P=0.031), capsular/extrathyroidal invasion (P=0.033), and positive lymph nodes of level VIA on the right side (P<0.001) were independent risk factors for LN-prRLN metastasis in cN0-stage PTC patients. A prediction model based on these factors was established and presented a visual nomogram. After validation, the AUC of this model in the training group and validation group were 0.870 (95% CI=0.807-0.933) and 0.857 (95% CI=0.750-0.964), respectively. The calibration curves for both the training and validation groups closely approximated the ideal curve, indicating that the predicted probabilities from the model were consistent with the actual probabilities. Decision curve analysis also demonstrated that applying this model in clinical practice resulted in clinical gains.Conclusion The visualized predictive nomogram model established based on independent risk factors for LN-prRLN metastasis in cN0-stage PTC, as determined by this study, helps to objectively and individually assess cervical lymph nodes, particularly the metastasis of LN-prRLN. It balances the surgical anatomical benefits and the risk of surgical complications, and provides evidence for whether LN-prRLN dissection should be performed, optimizing diagnosis and treatment.

7 Analysis of influencing factors for lateral neck lymph node metastasis in patients with papillary thyroid carcinoma

MA Xinyu , CHAI Fang , XIAO Zhiyuan , LIU Keyi , ZHENG Tong , LIU Xiaolin

2023, 32(5):682-689. DOI: 10.7659/j.issn.1005-6947.2023.05.007

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Background and Aims Papillary thyroid carcinoma (PTC) is the most prevalent pathological type among thyroid cancers, and lateral neck lymph node metastasis (LLNM) in PTC is the primary cause of patient recurrence and reoperation. Therefore, this study was conducted to analyze the clinical characteristics of PTC patients, explore the influencing factors for LLNM, and construct a clinical prediction model to provide a reference basis for determining an appropriate surgical scope.Methods The clinical data of patients with PTC who underwent surgical treatment at the First Affiliated Hospital of Jinzhou Medical University from March 2018 to January 2022 were retrospectively analyzed. The clinicopathologic factors between patients who experienced LLNM and those who did not were compared. Factors that showed statistical significance were included in a multiple Logistic regression analysis. Using R 4.1.3, a predictive nomogram model for LLNM risk in PTC patients was established, and a calibration curve was plotted to evaluate the accuracy of the model. The diagnostic cut-off values for independent risk factors for LLNM were determined using the ROC curve.Results A total of 597 PTC patients were included, and 187 cases (31.32%) had LLNM. Univariate analysis showed that age, tumor diameter, multifocal lesions, extrathyroidal invasion, central neck lymph node metastasis (CLNM), and BRAF^V600E gene mutation were significant factors influencing LLNM in PTC patients (all P<0.05). Age, tumor diameter, extrathyroidal invasion, presence of CLNM and BRAF^V600E gene mutation were identified as independent risk factors for LLNM (all P<0.05). Based on these factors, a predictive nomogram model for LLNM risk in PTC patients was constructed. The nomogram demonstrated that tumor diameter had the greatest impact on LLNM, while multifocal lesions had the least. Calibration curve analysis indicated that the nomogram model had a close fit to the ideal curve for predicting LLNM in PTC patients. According to the ROC curve analysis, the diagnostic cut-off value for tumor diameter as an independent risk factor for LLNM was 1.05 cm, and the cut-off value for age was 32.5 years.Conclusion PTC patients who have factors such as younger age, tumor diameter >1.05 cm, extrathyroidal extension, presence of CLNM, and BRAF^V600Egene mutation have a relatively higher risk of developing LLNM. The nomogram model constructed based on these factors demonstrates good calibration for predicting LLNM in PTC patients. When PTC patients exhibit these characteristics and have high nomogram scores, a more cautious approach should be taken in the preoperative assessment and intraoperative exploration of their lateral neck lymph nodes, and appropriate treatment measures should be implemented to improve their prognosis.

8 Diagnostic value of thyroglobulin detection in washout fluid of fine-needle aspiration biopsy for cervical lymph node metastasis in papillary thyroid carcinoma

WANG Yanan , ZHANG Huan , OUYANG Xiangliu , HAN Yunxia , LIU Liyun , ZHENG Lichun

2023, 32(5):690-697. DOI: 10.7659/j.issn.1005-6947.2023.05.008

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Background and Aims The current diagnosis of neck lymph node metastasis in papillary thyroid carcinoma (PTC) relies mainly on ultrasound and fine-needle aspiration cytology (FNAC). However, both methods have subjectivity and limitations. This study was conducted to investigate the application value of detection of thyroglobulin in the washout fluid from fine-needle aspiration biopsy (FNA-Tg) under ultrasound guidance for cervical lymph node metastasis in PTC patients.Methods The data of 144 patients with pathologically confirmed PTC were retrospectively analyzed. Preoperatively, all patients underwent serum thyroglobulin (Tg) testing, and suspicious cervical lymph nodes were subjected to ultrasound-guided FNAC and FNA-Tg testing. The postoperative final pathological results were considered as the gold standard. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of FNAC, FNA-Tg, and their combination in diagnosing neck lymph node metastasis in PTC patients were compared. Receiver operating characteristic (ROC) curves were plotted for each diagnostic method, and the area under the ROC curve (AUC) was calculated to determine the optimal diagnostic threshold for the quantitative parameter FNA-Tg.Results A total of 176 lymph nodes were examined in 144 PTC patients. Among them, 81 lymph nodes were diagnosed as metastatic PTC and 95 lymph nodes were non-metastatic. The serum Tg and FNA-Tg levels in the metastatic lymph node group were 28.84 (7.42-84.22) ng/mL and 500 (142.56-500) ng/mL, respectively. In the non-metastatic lymph node group, the serum Tg and FNA-Tg levels were 20.11 (9.57-38.30) ng/mL and 0.10 (0.10-0.29) ng/mL, respectively. There was no statistically significant difference in serum Tg between the two groups (Z=1.878, P=0.062), while there was a statistically significant difference in FNA-Tg between the two groups (Z=10.981, P<0.001). The AUC of ROC curve for FNA-Tg in diagnosing metastatic PTC lymph nodes was 0.964 (95% CI=0.937-0.992, P<0.001), with the optimal diagnostic cut-off value of 4.79 ng/mL. The AUC of ROC curve for FNAC in diagnosing metastatic PTC lymph nodes was 0.840 (95% CI=0.777-0.903, P<0.001). When FNA-Tg and FNAC were used together to diagnose metastatic PTC lymph nodes, the AUC of ROC curve was 0.960 (95% CI=0.927-0.994, P<0.001). The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value in diagnosing metastatic PTC lymph nodes were 81.48%, 85.26%, 83.52%, 82.50%, 84.38% for FNAC, and 92.59%, 93.68%, 93.18%, 92.59%, 93.68% for FNA-Tg, respectively. When FNA-Tg and FNAC were used together, the values were 96.30%, 95.79%, 96.02%, 95.12%, and 96.81%. There were statistically significant differences in sensitivity, accuracy, and negative predictive value between FNAC and FNA-Tg (χ²=4.432, P=0.035; χ²=7.798, P=0.005; χ²=4.228, P=0.040). However, there was no statistically significant difference in specificity and positive predictive value (χ²=3.576, P=0.059; χ²=3.768, P=0.052). and all diagnostic indicators were improved by the combination of FNA-Tg and FNAC.Conclusion FNA-Tg measurement is an objective quantitative diagnostic method that has high diagnostic value in detecting cervical lymph node metastasis in PTC. It is superior to FNAC, and when FNA-Tg measurement is combined with FNAC, it further enhances the diagnostic performance.

9 Analysis of prognostic factors and nomogram construction for postoperative survival of medullary thyroid carcinoma

GUO Yao , DAN Jiaqiang , YUAN Zhiying

2023, 32(5):698-706. DOI: 10.7659/j.issn.1005-6947.2023.05.009

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Background and Aims The current main approach for assessing the prognosis of medullary thyroid carcinoma (MTC) is the TNM staging system, but it cannot provide individualized prognosis prediction for patients. Therefore, there is a need to develop a precise prognostic indicator system specifically for MTC. This study was conducted to analyze the factors influencing postoperative survival in MTC patients and construct a postoperative survival nomogram for MTC.Methods MTC data from the SEER database from 2004 to 2015 were selected, and a total of 1 884 eligible patients were included in the study. The patients were randomly divided into a training set (1 413 cases) and a validation set (471 cases) at a ratio of 3∶1. The baseline clinical data and characteristics were compared between the two groups. Univariate and multivariate Cox regression models were used to identify independent factors for MTC survival, and Kaplan-Meier survival curves were used to analyze their impact on prognosis. A survival nomogram for postoperative MTC patients was established based on the results of Cox regression analysis. The nomogram was validated and evaluated using concordance index, ROC curve, area under the curve (AUC), calibration curve, and decision curve analysis (DCA).Results The results of univariate analysis showed that sex, age, primary tumor stage, lymph node metastasis, distant metastasis, total thyroidectomy, extrathyroidal. invasion, and radiotherapy were all associated with patients' prognosis (all P<0.05). The results of Cox regression analysis showed that sex, age, distant metastasis, extrathyroidal. invasion, total thyroidectomy, and radiotherapy were independent prognostic factors for MTC patients (all P<0.05). Kaplan-Meier survival curves demonstrated that male patients, age ≥49 years, presence of distant metastasis, extrathyroidal invasion, absence of total thyroidectomy, and receipt of radiotherapy had worse prognosis. Nomograms for 2-, 5-, and 10-year survival of MTC patients were constructed using variables that included sex, age, distant metastasis, and extrathyroidal invasion and surgical procedure. The concordance index for the training set of the nomogram was 0.755 (95% CI=0.741-0.769), and for the validation set, it was 0.725 (95% CI=0.699-0.769). The ROC curve was used to evaluate the discriminatory ability of the nomogram, with AUC values of 0.79, 0.779, and 0.766 for the training set at 2-, 5-, and 10-years, respectively, and 0.78, 0.725, and 0.733 for the validation set. The calibration curve showed good consistency between the predicted survival rates and actual survival rates. DCA demonstrated that the nomogram had greater net benefit compared to the AJCC 6th edition TNM staging system in 5- and 10-year survival assessment.Conclusion Sex, age, distant metastasis, extrathyroidal. invasion, and surgical approach are independent factors influencing the survival of MTC patients. The postoperative survival nomogram model for MTC can provide more accurate individual survival prediction to assist clinicians in making appropriate personalized clinical decisions.

10 Evidence-based visualization study on the progress of diagnosis and treatment for thyroid cancer based on bibliometrics

LI Yang , WANG Quan , YANG Kelu , NIU Mingming , YANG Sijie , LI Ruishu , JIANG Kewei

2023, 32(5):707-717. DOI: 10.7659/j.issn.1005-6947.2023.05.010

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Background and Aims Thyroid cancer is the most common malignancy of the endocrine system globally, with its incidence increasing each year. It ranks fourth among malignant tumors in females, contributing to a growing healthcare burden. In recent years, advancements in medical technology and changes in thyroid cancer diagnosis and treatment approaches have significantly improved the survival prognosis for patients. Based on the previous bibliometric research conducted by our team on thyroid cancer, this study was performed to analyze the dynamic evolution of the development as well as diagnostic and treatment patterns of thyroid cancer worldwide by utilizing clustering analysis and theme mining techniques, with different time horizons as the research object, in order to predict future research trends in thyroid cancer and provide valuable insights for the future direction of thyroid cancer diagnosis and treatment.Methods The thyroid cancer-related studies from the Web of Science database were retrospectively collected. The VOSviewer 1.6.18 software was used to extract variables such as research topics, keywords, author information, and publication years from the included literature. Clustering analysis, temporal analysis, and topic mining were performed to explore the research themes of published studies on thyroid cancer using bibliometric methods. The dynamic evolution process of thyroid cancer diagnosis and treatment patterns within different time periods was examined, and future research hotspots were predicted.Results A total of 32 074 publications on thyroid cancer-related research topics were included in the analysis, with the earliest publication dating back to 1955. Over time, the number of publications increased rapidly. Globally, based on the published literature, the development of thyroid cancer can be roughly divided into three stages through clustering analysis. These stages were as follows: 1. Exploratory treatment stage under empirical medicine guidance (1955-1990, Stage 1): A total of 2 713 eligible publications were published during this stage. Initially, the focus in the field of thyroid cancer was on its epidemiological characteristics, the relationship with antithyroglobulin indicators, follow-up prognosis, etc. However, during this stage, ideal clustering among various key terms was not yet established. 2. Standardized treatment stage under evidence-based medicine principles (1991-2000, Stage 2): A total of 2 845 eligible publications were published during this stage. The research focus shifted to the treatment and prognosis of thyroid cancer, including topics such as radioactive iodine therapy, ablation therapy, distant metastasis, etc. Since 1996, there has been increasing attention from the industry on the epidemiology, diagnosis, treatment, basic research, and prognosis of thyroid cancer. 3. Individualized treatment stage under the guidance of precision medicine (2001-2022, Stage 3): A total of 26 516 eligible publications were published during this stage. The research focus primarily revolved around the basic research of thyroid cancer, including BRAF mutations, mRNA, signaling pathways, etc. Molecular mechanism studies of thyroid cancer (such as non-coding RNA and the search for more ideal biomarkers to assist in diagnosis, monitoring, and prognosis) and the development of novel drugs for thyroid cancer treatment were the current key areas of interest for researchers in this stage.Conclusion The field of thyroid cancer research has seen a growing emphasis on related basic studies. It is predicted that future research hotspots will predominantly concentrate on the development of new targeted drugs for thyroid cancer and the exploration of more ideal biomarkers.

11 "Five-settlement method" for gasless endoscopic mesothyroid excision via unilateral axillary approach

GE Junna , YU Shitong , TAN Jie , CHEN Weisheng , LI Tingting , ZHANG Zhicheng , SUN Baihui , WEI Zhigang , LEI Shangtong

2023, 32(5):718-723. DOI: 10.7659/j.issn.1005-6947.2023.05.011

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Based on gross anatomical observations and clinical experience, our center proposed the concept of mesothyroid excision in 2014. We have consistently applied this technique to guide open thyroidectomy and central compartment neck dissection for malignant thyroid tumors. The advantage of this technique is its ability to achieve a more thorough en bloc removal of the central compartment lymph nodes while ensuring the safety of the recurrent laryngeal nerve. In recent years, transaxillary endoscopic thyroid surgery has been rapidly promoted in our country. Our center began performing transaxillary endoscopic thyroid surgery in 2019 and made improvements to the gasless transaxillary endoscopic thyroid surgery under the theoretical guidance of our previous mesothyroid excision technique. To facilitate thyroid surgeons in mastering this technique, this article disassembles and assembles the theory into the "five-settlement method" of surgical operation with detailed explanations.

12 "Scene-based" approach for gasless transaxillary posterior endoscopic thyroidectomy

SUN Baihui , YU Shitong , GE Junna , WEI Zhigang , LEI Shangtong

2023, 32(5):724-730. DOI: 10.7659/j.issn.1005-6947.2023.05.012

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With the development and promotion of endoscopic thyroid surgery, transaxillary endoscopic thyroid surgery has been proven to be a safe and feasible surgical method. Among them, gasless transaxillary posterior endoscopic thyroid surgery (GTPET) has been widely accepted and adopted due to its clear field of vision without gas interference. However, due to the characteristics of the lateral viewing angle, shared surgical space of the lens and instruments, inherent difficulties exist in the surgical operation. To solve the problem of visual angle coordination in endoscopic operations, some teams have applied an assistant robot. However, for GTPET, which has a small operating range, the surgical view and operation still depend on the coordination of the surgeon and the camera-holding assistant. To overcome the difficulties in GTPET procedures, the author introduces the concept of "scene-based" operations, focusing on the perspective of the camera-holding assistant. This involves standardizing the assistant's operational procedures during the GTPET surgery into three parts. Firstly, preoperative preparation: standardizing patient positioning and the location of the camera-holding assistant. Secondly, key points for the assistant's operation: summarized as "one pivot," "two approaches," and "three planes." Thirdly, the "four-quadrant" method was used to assist the operation by visualizing the field of endoscopic view, dividing the surgical area into zones I to Ⅳ and guiding the surgical procedures accordingly.

13 Expressions of lncRNA MIR31HG and miR-101 in differentiated thyroid cancer tissues and their clinical significance

TONG Ning , LIU Zhibo , SHAO Yugui , ZHANG Di

2023, 32(5):731-738. DOI: 10.7659/j.issn.1005-6947.2023.05.013

[Abstract](442) [HTML](544) [PDF 820.33 K](1074)

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Background and Aims Studies have shown that abnormal expressions long non-coding RNAs (lncRNAs) and microRNAs (miRNAs) and the interaction between them play important roles in the occurrence and development of malignant tumors. This study was conducted to investigate the expression characteristics of lncRNA MIR31HG and miR-101 in differentiated thyroid cancer tissues of patients, as well as their relationship with clinicopathologic features and prognosis.Methods The expression levels of lncRNA MIR31HG and miR-101 in the surgical specimens of tumor tissue and adjacent non-tumor tissue form 92 patients with differentiated thyroid cancer were detected using qRT-PCR. The clinical and follow-up data of the patients were collected, and the relationship between the expressions of these two molecules and clinicopathologic factors was analyzed. Kaplan-Meier analysis was used to analyze patient survival rates, and the Cox proportional hazards regression model was used to analyze factors for poor prognosis in patients.Results The relative expression level of lncRNA MIR31HG was significantly higher while the relative expression level of miR-101 was significantly lower in differentiated thyroid cancer tissue than those in adjacent non-tumor tissue (both P<0.01). The relative expression levels of lncRNA MIR31HG and miR-101 were significantly associated with clinical stage, differentiation degree, and lymph node metastasis of patients (all P<0.05). Patients with high expression of lncRNA MIR31HG had lower cumulative survival rates than those with its low expression (84.7% vs. 94.6%, χ²=7.032, P=0.016), and patients with low expression of miR-101 had lower cumulative survival rates than those with its high expression (78.3% vs. 95.6%, χ²=8.482, P=0.004). Clinical stage Ⅲ-Ⅳ, high differentiation degree, lncRNA MIR31HG relative expression level >1.5, and miR-101 relative expression level <0.5 were identified as risk factors for poor prognosis in differentiated thyroid cancer (all P<0.05).Conclusion Upregulation of lncRNA MIR31HG and downregulation of miR-101 in DTC tissues are risk factors for poor prognosis in differentiated thyroid cancer, suggesting that they could serve as prognostic markers for differentiated thyroid cancer.

14 Analysis of the efficacy and survival outcomes of neoadjuvant chemotherapy in breast cancer patients with different HER-2 expression levels

WANG Xiaomin , PENG Lushan , WANG Xiaoxiao , ZHANG Qian , ZHANG Hanghao , PENG Shuai , LIAO Liqiu

2023, 32(5):739-751. DOI: 10.7659/j.issn.1005-6947.2023.05.014

[Abstract](1354) [HTML](534) [PDF 1.00 M](1187)

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Background and Aims Neoadjuvant chemotherapy is an important treatment strategy for breast preservation after downstaging and improving overall cure rates in early high-risk or locally advanced breast cancer. The selection of patients and the development of treatment plans for neoadjuvant chemotherapy depend on molecular subtypes. However, there is currently a lack of research on the efficacy of neoadjuvant chemotherapy and differences in survival prognosis based on the expression levels of human epidermal growth factor receptor 2 (HER-2) in breast cancer. Therefore, this study was performed to compare the efficacy of neoadjuvant chemotherapy and differences in survival prognosis among breast cancer patients with different levels of HER-2 expression, and identify the factors influencing the efficacy of neoadjuvant chemotherapy and survival prognosis, so as to provide valuable insights for the selection of patients and development of treatment plans for clinical neoadjuvant chemotherapy.Methods The data of breast cancer patients who underwent neoadjuvant chemotherapy and radiacal mastectomy in the Department of Breast Surgery, Xiangya Hospital, Central South University, from January 2018 to May 2022 were retrospectively analyzed. The differences in clinicopathologic characteristics among patients with different HER-2 expression levels (zero-expression, low-expression, overexpression) were compared. Logistic regression analysis was used to identify independent factors influencing pathological complete response (pCR). Kaplan-Meier method was employed to estimate survival curves, and the Log-rank test was used to compare differences in survival rates. Cox regression analysis was conducted to identify independent prognostic factors.Results A total of 601 patients were included, among whom 231 (38.4%) had HER-2 zero-expression, 137 (22.8%) had HER-2 low-expression, and 233 (38.8%) had HER-2 overexpression. Compared to patients with HER-2 zero-expression and HER-2 overexpression, patients with HER-2 low-expression had higher BMI value, fewer cases of family history of tumors, lower histological grades, and a higher proportion of hormone receptor (HR) positivity; the degree of tumor fibrosis was significantly lower in patients with HER-2 overexpression compared to those with HER-2 zero-expression and HER-2 low-expression (all P<0.05). Among patients with HER-2 low-expression, the HR-negative subgroup had larger tumor size, higher histological grades, and higher Ki-67 level compared to the HR-positive subgroup (all P<0.05). In the entire cohort, HER-2 expression level, pCR, and clinical lymph node stage (cN) were independent factors influencing disease-free survival (DFS) (all P<0.05). Patients with HER-2 overexpression had significantly higher pCR and DFS rates after neoadjuvant chemotherapy compared to those with HER-2 low-expression and HER-2 zero-expression (all P<0.05), but there was no significant difference in neoadjuvant chemotherapy pCR and DFS rates between patients with HER-2 low-expression and HER-2 zero-expression (all P>0.05). Tumor fibrosis and estrogen receptor (ER) status were independent factors influencing pCR in HER-2 zero-expression breast cancer, while stromal tumor-infiltrating lymphocytes (sTILs) were independent factors influencing pCR in HER-2 low-expression breast cancer, and tumor fibrosis and ER status were independent factors influencing pCR in HER-2 overexpression breast cancer (all P<0.05).Conclusion Neoadjuvant chemotherapy is more effective in breast cancer patients with HER-2 overexpression compared to those with HER-2 zero-expression and low-expression. ER status, fibrosis degree, and sTILs level are independent factors influencing pCR in patients with HER-2 zero-expression and low-expression, while ER status and fibrosis degree are independent factors influencing pCR in patients with HER-2 overexpression.

15 Clinicopathologic characteristics, diagnosis and treatment strategies of occult breast cancer: a report of 12 cases

ZHANG Huimin , XIE Peiling , LI Yijun , ZHOU Can , HE Jianjun

2023, 32(5):752-760. DOI: 10.7659/j.issn.1005-6947.2023.05.015

[Abstract](766) [HTML](1121) [PDF 818.86 K](1245)

Abstract:
Background and Aims Occult breast cancer (OBC) is a rare type of breast cancer with low incidence and difficulty in identifying the primary breast lesion, leading to a vague definition and diagnosis for healthcare professionals. Additionally, due to the lack of large-scale clinical studies on the management strategies for OBC, the local and systemic treatment options, as well as prognosis information, pose considerable challenges for clinicians. This study was performed to attempt to provide clinical references by analyzing the clinical and pathological characteristics of 12 cases of OBC, summarizing the diagnostic and therapeutic process, and discussing the diagnostic and treatment strategies for OBC based on domestic and international literature.Methods A retrospective analysis was conducted on 12 cases of OBC patients treated in the Department of Breast Surgery at the First Affiliated Hospital of Xi'an Jiaotong University from May 2013 to April 2020. The clinicopathologic characteristics, MRI findings, treatment strategies, efficacy of neoadjuvant chemotherapy, and prognosis of these patients were analyzed.Results Of the 12 patients, the median age was 53 years, histological subtypes consisted of poorly differentiated adenocarcinoma, infiltrating ductal carcinoma, and carcinoma simplex, accounting for 66.7%, 25.0%, and 8.3% respectively. The molecular subtypes were luminal B type, HER-2 positive type, and triple-negative type, with proportions of 41.7%, 8.3%, and 50.0% respectively. According to the AJCC staging, 25.0% were stage Ⅱ, 58.3% were stage Ⅲ, and 16.7% were stage Ⅳ. MRI findings indicated unilateral axillary lymph node enlargement in 9 cases (75.0%), with 3 cases on the right side and 6 cases on the left side. Bilateral axillary lymph node enlargement was found in 1 case (8.3%). MRI revealed axillary lymph node enlargement and supraclavicular lymph node enlargement on the right side in 2 cases (16.7%). No suspicious malignant lesions were detected in the breast region on MRI in any of the patients. Among the 10 patients with non-stage Ⅳ OBC, 8 underwent modified radical mastectomy, 2 underwent axillary lymph node dissection only, and 2 patients diagnosed with stage Ⅳ at initial presentation did not undergo surgery. Three patients received neoadjuvant chemotherapy, and two of them achieved pathological complete response (pCR). The median follow-up time was (43±14) months. As of July 2022, six patients experienced recurrence and metastasis, with three deaths attributed to visceral metastasis.Conclusion Breast MRI examination has important value in the exclusionary diagnosis of OBC. The treatment strategy for OBC can involve neoadjuvant therapy, modified radical mastectomy, axillary lymph node dissection based on molecular subtypes and lymph node staging. Postoperative adjuvant radiotherapy, chemotherapy, and endocrine therapy may be considered as adjunctive treatments.

16 Analysis of clinicopathologic characteristics and prognostic risk factors in T1 stage breast cancer

ZHANG Qian , PENG Shuai , WANG Xiaomin , WANG Xiaoxiao , ZHANG Hanghao , LIAO Liqiu

2023, 32(5):761-770. DOI: 10.7659/j.issn.1005-6947.2023.05.016

[Abstract](544) [HTML](861) [PDF 922.51 K](1196)

Abstract:
Background and Aims T1 stage breast cancer patients have an overall favorable prognosis, but there is still a small subset of patients who exhibit high invasiveness and are prone to adverse outcomes such as recurrence, metastasis, and death, leading to a poorer prognosis. This study was conducted to investigate the clinicopathologic characteristics that influence T1 stage breast cancer and determine the risk factors associated with prognosis, for early identification of high-risk T1 stage breast cancer patients and providing reference for clinical decision-making.Methods The data of 1 250 patients with primary invasive breast cancer at stages T1 to T3 who underwent surgical treatment at Xiangya Hospital, Central South University, from January 2011 to December 2015 were retrospectively analyzed. The differences in clinicopathologic characteristics between T1 and non-T1 stage patients were determined. Univariate and multivariate Cox regression models were used to analyze the risk factors affecting recurrence, metastasis, and death in T1 stage breast cancer patients. The Kaplan-Meier method was employed to assess the differences in overall survival (OS) and disease-free survival (DFS) among T1 stage breast cancer patients with different risk factors, and the Log-rank test was used to compare the survival curves between groups.Results Among the 1 250 patients with primary invasive breast cancer, there were 261 cases (20.88%) at stage T1 and 989 cases (79.12%) at non-T1 stage (T2 and T3). Compared to non-T1 stage patients, T1 stage patients had lower BMI value, fewer axillary lymph node metastases, fewer unfavorable biological characteristics, and better survival prognosis (all P<0.05). During the follow-up period, there were 15 deaths and 40 cases of recurrence and metastasis among T1 stage patients. The median OS was 94 (5-132) months, with 2-, 5-, and 10-year OS rates of 97%, 95%, and 94%, respectively. The DFS was 92 (4-138) months, with 2-, 5-, and 10-year DFS rates of 95%, 88%, and 82%, respectively. The results of the multivariate Cox regression model indicated that lymph node metastasis (HR=4.904, 95% CI=1.588-15.144, P=0.006) and unfavorable biological characteristics (HR=4.241, 95% CI=1.433-12.552, P=0.009) were independent risk factors for OS in T1 stage patients. Lymph node metastasis (HR=3.118, 95% CI=1.553-6.262, P=0.001), unfavorable biological characteristics (HR=2.295, 95% CI=1.034-5.093, P=0.041), and Ki-67>14% (HR=2.258, 95% CI=1.079-4.723, P=0.031) were independent risk factors for DFS in T1 stage patients. Survival analysis showed that among T1 stage patients with positive lymph node metastasis, those with favorable biological characteristics had no significant difference in OS and DFS compared to patients with negative lymph node metastasis (both P>0.05), while those with adverse biological characteristics had the worst OS and DFS (both P<0.05).Conclusion Overall, T1 stage invasive breast cancer patients have a relatively good prognosis. However, axillary lymph node metastasis and unfavorable biological characteristics are risk factors for early recurrence, metastasis, and death in T1 stage breast cancer patients. The combination of biological characteristics can further identify high-risk patients with T1 stage breast cancer and positive axillary lymph nodes, providing reference for treatment decisions in T1 stage breast cancer.

17 Hot topics and research advances in neoadjuvant therapy for HER-2 positive breast cancer

CHENG Rui , JI Wenxin , ZHOU Can , LI Shangpeng , DAI Yinhai

2023, 32(5):771-781. DOI: 10.7659/j.issn.1005-6947.2023.05.017

[Abstract](829) [HTML](880) [PDF 843.76 K](1340)

Abstract:
Currently, human epidermal growth factor receptor 2 (HER-2) positive breast cancer has become a focus and hotspot in the research of breast cancer treatment due to its unique target and therapeutic drugs. Early treatment is particularly important for diagnosed breast cancer. Breast cancer treatment is mainly divided into two categories: local treatment, including early breast-conserving surgery, sentinel lymph nodes, and regional lymph node radiotherapy, and systemic treatment, including neoadjuvant therapy and adjuvant therapy. Although surgical treatment is currently the main treatment for breast cancer, some patients require neoadjuvant therapy before surgery. The population receiving neoadjuvant therapy mostly consists of stage Ⅲ breast cancer or some stage IIA and IIB patients, highlighting the importance of neoadjuvant therapy. In light of these two points, neoadjuvant therapy for HER-2 positive breast cancer needs special attention. Currently, four hot topics in this area require further exploration: 1. The treatment of breast cancer with anthracycline drugs, which has sparked controversy among researchers due to its cornerstone role in neoadjuvant therapy for breast cancer and its cardiotoxic side effects. Whether it exacerbates the condition and affects surgical standards for patients with underlying diseases, especially heart-related issues, is a concern. 2. The selection of the neoadjuvant targeted therapy cycle. The choice of treatment duration is equally important. A short treatment period may not meet the surgical standards, while a long treatment duration may cause patients to miss the optimal surgical timing, delaying their condition. The patient's tolerance to extended treatment and their psychological state also impact the success of the surgery. 3. The selection of the optimal combination targeted therapy based on trastuzumab. Single-target therapy was strongly recommended by experts in the early stages of HER-2 positive breast cancer research. However, with the approval of more drugs in China, the use of dual-target drugs for treating HER-2 positive breast cancer has become a hot topic within the field. 4. The choice of dual-target therapy after neoadjuvant therapy for HER-2 positive breast cancer. The selection of dual-target therapy after neoadjuvant therapy depends on the patient's sensitivity to the drugs during neoadjuvant treatment and whether they achieve the patient's desired pathological complete response rate (pCR). The following discussion will delve into these four hot topics, providing new insights for clinical practice.

18 Research progress in intraoperative near-infrared fluorescence imaging for parathyroid identification

XU Huaisheng , WU Delin , MA Xiaopeng

2023, 32(5):782-787. DOI: 10.7659/j.issn.1005-6947.2023.05.018

[Abstract](588) [HTML](548) [PDF 619.41 K](1382)

Abstract:
In recent years, the number of thyroid surgeries has been increasing annually. Accurate identification and preservation of the parathyroid glands during surgery have always been important clinical concerns in thyroid surgery. In most cases, surgeons rely on subjective experience during surgery to identify the parathyroid glands, which can lead to inadvertent damage and subsequent hypoparathyroidism. Currently, the use of intraoperative near-infrared fluorescence imaging technique for parathyroid identification has become a hot topic in thyroid surgery research. Here, the authors provide a review of related studies.

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Volume 32,Issue 5,2023 Table of Contents

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