1. 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

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

3. TOETVA--- No scars---- NOTES

4. Oral vestubule and Trocars

5. Mental foramen and N
Foramen variants from canine to molar

6. 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

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

8. Pre-Operative FNA: low risk for malignancy

9. 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

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

11. Results

12. Table 1. Demographics N Age, (median, years) 41 (19~61) Gender : M F 126
Thyroid disease
Solitary nodule
Multiple nodules
Thyroiditis
Palpillary carcinoma
Follicular carcinoma 27
5 (18%)
4(15%)
1(4%)
16(59%)

13. 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

14. 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)

15. 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;

16. 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

17. 88.9% sensitivity / 100% specificity
Critical Cut Off = 25mm
88.9% sensitivity / 100% specificity
highest Youden index=1.889

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

19. 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

20. Discussion

21. Inter-canine, preMorlar, Molar

22. 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.

23. Thanks for Your Attention

24. 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.

25. 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