高雄長庚 一般外科 巫奕儒 紀順裕 詹怡嘉 周逢復 What’s the Appropriate Nodular Size in Thyroid Cancer without Breaking Specimens by Trans-oral Endosocpic Thyroidectomy Vestibule Approach? 高雄長庚 一般外科 巫奕儒 紀順裕 詹怡嘉 周逢復

Surg Lap Endosc Percut Tech (SCI) Decisions from SLEPT--- minor revision

TOETVA--- No scars---- NOTES

Oral vestubule and Trocars

Mental foramen and N Foramen variants from canine to molar

How to Extract from Oral Vestibule？ Benign nodular goiter: up to 4cm (Dr. Anuwong) fragmented/breaking pieces Malignant nodular goiter? affecting Patho. ETE and Treatment/Prognosis

Problems : ? Nodular Size in thyroid Ca by TOETVA Aim: Intact specimen without breaking Cosmetic results No mental N injury Safety

Pre-Operative FNA: low risk for malignancy

Study: Material and Methods 8/2016~7/2017: 27 patients : PreOP FNA I~IV low risk for malignancy Surgical path: 10: benign goiters 17: thyroid Ca Excluding 10 benign goiters: compare Fragment/ Intact Measure nodular size by echo

Group Division in Thyroid CA Fragmented, Group F Intact, Group T

Results

Table 1. Demographics N Age, (median, years) 41 (19~61) Gender : M F 1 26 Thyroid disease Solitary nodule Multiple nodules Thyroiditis Palpillary carcinoma Follicular carcinoma 27 5 (18%) 4(15%) 1(4%) 16(59%)

Table 2. Peri-Operative data Perioperative factors Values Nodules size by US, (median, mm) 26.3 (4~44) Thyroidectomy Unilateral (UT) Bilateral (BT) 18 9 Operative time (mediann, minues) UT BT 254 (115~356) 235 (115~356) 308 (208~335) Hospital stay (median, days) 3 (2~14) Complication Temporary/Permanent vocal cord palsy Temporary/Permanent Hypoparathyroidism 4 (14.81%) /0 1 (3.7%) /0 Mental nerve injury Infection 1 (3.70%) Converted to open

Table 3. FNA correlated with Surgical Pathology FNA cytopathology N Surgical Pathology Benign Malignant I (NDU) 6 4 (66.7%) 2 (33.3%) II Benign 13 4 (30.8%) 9 (69.2%) III (AUS/FLUS) 1 (16.7%) 5 (83.3%) IV (SFN) 2 1 (50%) I,non-diagnostic or unsatisfactory (NDU); II, benign; III,atypic of unknown significance or follicular lesion of unknown significance (AUS/FLUS); IV, suspicious for follicular neoplasm (SFN)

Nodular Size (median, mm) Table 4. Group division of thyroid cancers and extra-thyroid extension (ETE) Specimen (17) N / thyroidectomy Nodular Size (median, mm) Group T, Intact 7 18.4 (8.3~26.0) Group F, Fragmented 10 30.3 (23.8~40.4) ETE (3) Group T Group F 1 / BT 2 / CLT BT, bilateral thyroidectomy; CLT, completion thyroidectomy; ETE, extra-thyroid extension;

Table 5: Cut-off value of nodular size between group T and F . Table 5: Cut-off value of nodular size between group T and F Indicator Cutoff value (mm) Sensitivity Specificity Areas under ROC Nodular size 24.9≑25 87.5% 88.9% 0.986 *Asymptomatic significance, null hypothesis: true area=0.5 ROC, receiver of characteristic

88.9% sensitivity / 100% specificity Critical Cut Off = 25mm 88.9% sensitivity / 100% specificity highest Youden index=1.889

Safest Nodular Diameter = 20mm 100% sensitivity / 87.5% specificity Youden index=1.875.

Conculusion Axillary Alveolar area of Nipple Appropriate nodular size in thyroid cancer without breaking specimen should be ≤ 20mm >20mm should be removed from other site Axillary Alveolar area of Nipple

Discussion

Inter-canine, preMorlar, Molar

Drawback of FNA I~IV low sensi / High spec Under-estimate Malignancy of FNA I ~ IV the current BSRTC system underestimated malignancy rates from 15% to 88% Deniwar A, Hambleton C, Thethi T, Moroz K, Kandil E. Examining the Bethesda criteria risk stratification of thyroid nodules. Pathol Res Pract. 2015;211:345-8.

Thanks for Your Attention

Reviewer 1 There are some parallel ideas to "Transoral thyroidectomy: limitations, patients' safety, and own experiences" in Updates in Surgery - this could be added to the discussed literature. The statistic calculation is appropriate. The protocol number of the ethical committee should be added. In the discussion section the hybrid accesses to the thyroid mentioned in literature should be discussed as an alternative way to extract the specimen without cutting or breaking the tissue. The English language could be improved.

Reviewer 2 describe if the volume of the lobe the presence of multiple nodules increase the risk of specimen fragmentation describe if the anatomical features of the patients (e.g. BMI, Mallampati score, abnormalities of the cervical spine) make the extraction of the entire specimen more difficult