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Purpose Nipple-sparing mastectomy (NSM) has become increasingly popular due to improved cosmesis without compromising oncologic safety. Radial and inframammary incisions are usually used to achieve NSM, with periareolar incisions usually being avoided because of the risk to nipple-areola complex viability. In an attempt to maximize esthetic effects, we performed NSM through periareolar incision with immediate reconstruction. We report our initial experience. Methods This case series consisted of all consecutive patients (n = 34) who underwent NSM through a periareolar incision in our institution between August 2017 and December 2018. All patients underwent NSM through periareolar incision followed by immediate reconstruction with an implant or deep inferior epigastric perforator flap. Patient demographics, tumor and treatment characteristics, and short-term postoperative outcomes were reviewed. Results The mean patient age was 46.74 ± 6.69 years (range, 38-62 years), and the mean operation time was 96.68 ± 28.00 minutes. Indications included in situ cancer in 12 cases and invasive cancer in 22 cases. There was 1 major complication (postoperative hematoma) requiring operative reintervention. No other complications including fistula, implant exposure, or reconstruction failure was observed. At the time of writing, no case of local recurrence has been observed. Conclusion Our initial report shows that NSM with immediate reconstruction may successfully be performed through periareolar incision. This method maximizes esthetic effects and may be an appropriate surgical option for NSM.

After publication of this supplement [1, 2], it was brought to our attention that due to an error authors were missing in the following abstracts. This has now been included in this correction.

Background Postoperative thyroid stimulating hormone (TSH) suppression therapy is recommended for patients with intermediate- and high-risk differentiated thyroid cancer to prevent the recurrence of thyroid cancer. With the recent increase in small thyroid cancer cases, the extent of resection during surgery has generally decreased. Therefore, questions have been raised about the efficacy and long-term side effects of TSH suppression therapy in patients who have undergone a lobectomy. Methods This is a multicenter, prospective, randomized, controlled clinical trial in which 2,986 patients with papillary thyroid cancer are randomized into a high-TSH group (intervention) and a low-TSH group (control) after having undergone a lobectomy. The principle of treatment includes a TSH-lowering regimen aimed at TSH levels between 0.3 and 1.99 μIU/mL in the low-TSH group. The high-TSH group targets TSH levels between 2.0 and 7.99 μIU/mL. The dose of levothyroxine will be adjusted at each visit to maintain the target TSH level. The primary outcome is recurrence-free survival, as assessed by neck ultrasound every 6 to 12 months. Secondary endpoints include disease-free survival, overall survival, success rate in reaching the TSH target range, the proportion of patients with major cardiovascular diseases or bone metabolic disease, the quality of life, and medical costs. The follow-up period is 5 years. Conclusion The results of this trial will contribute to establishing the optimal indication for TSH suppression therapy in low-risk papillary thyroid cancer patients by evaluating the benefit and harm of lowering TSH levels in terms of recurrence, metabolic complications, costs, and quality of life.

BACKGROUND Robotic unilateral modified radical neck dissection (MRND) has been reported to be safe and achieves good oncologic results. However, there is no report of successful robotic bilateral MRND to date. We report the first case series of robotic bilateral MRND through the bilateral axillo-breast approach (BABA). METHODS AND RESULTS We reviewed 4 patients who presented with papillary thyroid cancer and metastasis to both lateral neck compartments. BABA robotic total thyroidectomy with bilateral MRND was performed. There were no incidences of vocal cord palsy, permanent hypoparathyroidism, or chyle leakage. All patients underwent high-dose radioiodine ablation. At last follow-up, imaging tests showed no recurrence and thyroglobulin levels remained low. CONCLUSIONS BABA allows complete compartment-oriented neck dissection with outcomes that may be comparable with open bilateral MRND. BABA robotic surgery could be a good alternative for patients with papillary thyroid cancer and bilateral neck metastasis who wish to avoid long neck scar.

OBJECTIVES This study investigated the potential advantages of robotic thyroidectomy and determined whether it is safe and complete compared with conventional open surgery in patients with papillary thyroid cancer. MATERIALS AND METHODS A total 376 consecutive patients who underwent total thyroidectomy and central neck dissection for papillary thyroid cancer from February 2013 to July 2014 were retrospectively reviewed. Postoperative complication rates and surgical completeness were compared between the robotic and open groups. RESULTS Transient hypoparathyroidism was higher in the open group (10.5%) compared with the robotic group (2.8%; P=0.042). There were no differences in mean number of retrieved or metastatic lymph nodes. The mean values of stimulated thyroglobulin level were acceptably low in both groups. There was no difference in the proportion of patients with stimulated thyroglobulin levels

Robotic thyroidectomy has many advantages with comparable oncologic safety over conventional open surgery in low-risk differentiated thyroid cancer cases. However, there have been few reports on the outcomes of patients who have been treated with robotic thyroidectomy for more advanced thyroid cancer. The aim of this study was to investigate the validity of expanding indications of robotic thyroidectomy for more advanced thyroid cancer. The data of 80 patients with thyroid cancer who underwent robotic total thyroidectomy between January 2013 and December 2014 performed by a single surgeon at Chung-Ang University Hospital were retrospectively reviewed. Among them, 40 patients who had cancer larger than 2 cm or suspicious capsular invasion, or central lymph node (LN) metastasis in preoperative pathologic and radiologic examinations were categorized into the more advanced thyroid cancer group and the remaining patients into the early thyroid cancer group. We compared surgical safety and surgical completeness parameters between the two groups. The patients in more advanced thyroid cancer group had larger tumors, more extrathyroidal extension, and higher T stages. Surgical safety parameters, such as hypoparathyroidism, vocal cord palsy, and other complications did not differ significantly between the two groups. Surgical completeness parameters, such as the mean number of retrieved LNs, median values of the stimulated thyroglobulin levels, and the proportion of patients with stimulated thyroglobulin levels less than 1 ng/mL, also did not differ significantly. The outcomes of the patients with more advanced thyroid cancer who were treated with robotic thyroidectomy were comparable to those of the early cancer group patients. Well-designed investigations that are conducted at multiple centers are needed to affirm the validity of expanding indications of robotic thyroidectomy.

Purpose Various methods of sentinel lymph node (SLN) biopsy in thyroid cancer have been introduced. Tc-99m phytate as a radiotracer has been successfully utilized for SLN biopsy in breast, cervix, and endometrial cancer. We assessed the feasibility of SLN dissection using Tc-99m phytate in papillary thyroid carcinoma (PTC). Methods Seventeen patients with PTC were prospectively enrolled. Ultrasound-guided peritumoral injection of 55.5 MBq Tc-99m phytate in 0.25-mL normal saline was performed. Preoperative single-photon emission-computed tomography (SPECT) and intraoperative gamma-probe were used for SLN detection during operation. Results Identification rate of SLNs was 70.6% (12 of 17) with SPECT, and 88.2% (15 of 17) with gamma-probe. Combined SPECT and gamma-probe had identification rates of 88.2% (15 of 17). Identification rates of SLNs in central LN compartments were 82.4% (14 of 17) and 41.2% (7 of 17) in lateral LN compartments. Overall sensitivity, specificity, positive predictive value, and negative predictive value of the results of SLN biopsy were 91.6%, 100%, 88.4%, and 100%, respectively. Eight patients (47.1%) had metastasis in SLNs; all patients had SLN metastasis in the central compartment and 2 patients had SLN metastasis in both the central and lateral compartments. Conclusion Combined SPECT and gamma-probe could detect SLNs with an 88.2% identification rate in PTC. SLN biopsy using Tc-99m phytate is technically feasible. Further investigation is warranted for clinical application of Tc-99m phytate in PTC.

A robotic approach for thyroid surgery was developed to overcome the limitations of endoscopic thyroidectomy and provide many technical advantages. This approach facilitates the surgeon’s control through a magnified three-dimensional view, decreased tremor, and freedom of motion with articulated instruments. Robotic thyroidectomy is safe and technically feasible in patients with well-differentiated, low-risk thyroid cancer. Furthermore, robotic thyroidectomy may become a good surgical alternative option for patients with more advanced thyroid cancer. Our modified bilateral axillo-breast approach (BABA) for central and lateral cervical neck lymph node (LN) dissection has yielded excellent surgical outcomes as an open procedure. The incorporation of robotics in thyroid cancer surgery will continue to evolve, and the surgical indications for robotic thyroidectomy will continue to expand. Further analyses that include long-term outcomes and randomized comparative trials remain important.

Robotic thyroid surgery using the da Vinci surgical system has certain cosmetic advantages; however, the invasiveness of robotic thyroid surgery is still a concern to many surgeons. Previous research has not directly compared the surgical stress of robotic thyroidectomy with that of conventional open surgery. The aim of the present study was to evaluate surgical stress using postsurgical measurements of several clinical markers. A pilot study was performed to evaluate surgical stress following robotic and open thyroid surgery. A total of 29 papillary thyroid cancer patients from July to November 2014 were enrolled. Fourteen patients underwent conventional open surgery, and fifteen underwent robotic thyroidectomy. IL-6 levels, serum WBC counts, CRP levels, surgical plethysmographic index (SPI), and visual analogue scale (VAS) score were measured to compare surgical stress between the robotic and the open surgery groups. No significant differences were seen between the two groups in IL-6 level, WBC count or CRP level (p = 0.380, 0.374, 0.360, respectively). Mean SPI level during the surgery was 41.9 ± 4.7 in open group compared to 39.5 ± 2.2 in robotic group, though this finding showed borderline significance (p = 0.095). VAS score after open surgery was significantly higher than after robotic operation (p = 0.048). The results of this study suggest that robotic thyroidectomy can result in a less than equivocal systemic stress response than is seen in open thyroidectomy. However, further investigation including large-scale, prospective, multicenter studies is warranted for non-inferiority trials.

There is ongoing debate about whether or not robot-assisted thyroidectomy is appropriate for modified radical neck dissection (MRND). The purpose of this study was to compare the surgical outcomes of robot-assisted MRND with those of a conventional open procedure. One hundred and forty-five patients who underwent total thyroidectomy, bilateral central neck dissection, and MRND (robotic, n = 28; open, n = 117) at our institution from June 2011 to June 2015 were enrolled in the study. The surgical completeness and complication rates in the robotic and open groups were retrospectively compared after 1:3 propensity score matching for age, sex, body mass index, tumor size, and extrathyroidal extension. The complication rates, including transient or permanent hypoparathyroidism and recurrent laryngeal nerve palsy, were comparable between the study groups (p > 0.05). The operating time was significantly longer in the robotic group than in the open group (p

The Currarino triad is a unique complex of congenital caudal anomalies, including anorectal malformation, sacral bony defect and presacral mass. This triad may be associated with Mullerian duct anomalies, such as duplication of the vagina and uterus. Each of these diseases has a familial tendency and sometimes coexist within families. But, when coexisting in familial cases, nearly all reported cases revealed mutations of the motor neuron and pancreas homeobox 1 (MNX1) gene. Familial cases of Currarino triad combined with Mullerian duct anomaly without MNX1 gene mutation are very rare. Here we report cases of mother and daughter, who had Currarino triad and Mullerian duct anomaly without MNX1 gene mutation, along with a brief literature review.

Background We evaluated the effects of ropivacaine for pain relief after robotic thyroid surgery. Methods One hundred eight patients scheduled for robotic thyroid surgery were randomized into ropivacaine (n = 54) or control (n = 54) groups. After surgery, 40 mL of 0.25% ropivacaine or 0.9% saline (control) was instilled into the skin flap. Postoperative pain intensity (visual analog scale [VAS]), analgesic requirements (fentanyl), and adverse events were assessed at 1, 2, 4, 8, 16, and 24 hours postoperatively. Results One hundred three patients completed the study protocol. VAS scores were lower in the ropivacaine group than the control group (p = .010); however, VAS scores were not significantly different after 8 hours postoperatively. Total analgesic consumption was higher in controls than ropivacaine-treated patients (p = .01). Adverse events did not differ between the 2 groups. Conclusion Ropivacaine instillation after robotic thyroid surgery reduces acute postoperative pain and analgesic requirements without adverse events. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Background The BRAF V600E mutation is highly specific for papillary thyroid carcinoma (PTC). A test for this mutation can increase the diagnostic accuracy of fine-needle aspiration cytology (FNAC), but a considerably high false-negative rate for the BRAF V600E mutation on FNAC has been reported. In this study, we investigated the risk factors associated with false-negative BRAF V600E mutation results on FNAC. Methods BRAF V600E mutation results of 221 PTC nodules between December 2011 and June 2013 were retrospectively reviewed. BRAF V600E mutation results on both preoperative FNAC and postoperative formalin-fixed, paraffin-embedded (FFPE) samples were compared. We investigated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of BRAF V600E mutation results on FNAC. And, we identified the risk factors associated with false-negative results. Results Of 221 PTC nodules, 150 (67.9%) on FNAC and 185 (83.7%) on FFPE samples were BRAF V600E mutation positive. The sensitivity, specificity, PPV, and NPV for BRAF V600E mutation testing with FNAC were 80.5, 97.2, 99.3, and 49.3%, respectively. Thirty-six (16.3%) BRAF V600E mutation-negative nodules on FNAC were mutation positive on FFPE sample analysis. Risk factors for these false-negative results were age, indeterminate FNAC results (nondiagnostic, atypia of undetermined significance (AUS), and findings suspicious for PTC), and PTC subtype. Conclusion False-negative rate of BRAF mutation testing with FNAC for thyroid nodules is increased in cases of old age, indeterminate FNAC pathology results, and certain PTC subtypes. Therapeutic surgery can be considered for these cases. A well-designed prospective study with informed consent of patients will be essential for more informative results.

Purpose The availability of intraoperative parathyroid hormone (IOPTH) monitoring allows successful focused parathyroidectomy for primary hyperparathyroidism (pHPT). The objective of this study was to report our initial experience in IOPTH monitoring during parathyroid surgery for primary hyperparathyroidsim. Methods Between May 2011 and February 2013, 37 patients underwent focused parathyroidectomy due to pHPT. IOPTH monitoring based on Miami criteria was used to confirm complete excision of hyperfunctioning parathyroid gland during surgery. Medical records of patients were reviewed retrospectively. Results Preoperative mean maximal calcium level was 11.7 ± 0.9 mg/dL. Preoperative technetium (99mTc) sestamibi scan and ultrasonography identified 32 of 37 (86.5%) and 29 of 37 (78.4%) of abnormal parathyroid glands, retrospectively. Results of the 2 imaging modalities were discordant for 8 cases (21.6%). The mean pre-excision PTH level was 147.2 ± 201.5 pg/mL. At 5- and 10-minute post tumor resection, PTH levels were 65.3 ± 25.4 pg/mL and 47.5 ± 24.3 pg/mL, respectively. In all cases, IOPTH levels fell by at least 50% after removing all suspected abnormal glands. All patients had a successful return to normocalcemia after surgery (mean follow-up period: 60.2 ± 15.4 months). Conclusion Surgeon could confirm complete excision of abnormal hyperfunctioning parathyroid glands by IOPTH monitoring during surgery for pHPT. IOPTH monitoring can maximize performance of successful focused para thyroidectomy for pHPT, especially when preoperative imaging results are discordant.

Purpose Dendritic cells (DC) are a class of bone marrow-derived cells found in the blood, epithelia, and lymphoid tissues, and are the most efficient antigen presenting cells. The number and function of DC can change dramatically in cancer patients. The aim of this study is to correlate the levels of circulating DC subsets with clinical characteristics in breast cancer patients. Methods Peripheral blood samples were collected from 53 untreated breast cancer patients before surgery between January 2013 and November 2013. Forty-one healthy, age-matched volunteers served as the control group. The phenotypes of circulating plasmacytoid DCs (pDCs) and myeloid DCs (mDCs) were determined using fluorescence activated cell sorting assays. Correlations between DCs immunophenotypes and clinicopathologic characteristics of these breast cancer patients were then determined. Results Patients with breast cancer had higher levels of pDCs (p = 0.046). No relationships were observed with tumor stage and intrinsic subtype. Estrogen receptor (ER) positive patients had higher levels of mDCs than ER negative patients (p = 0.025) and human epidermal growth factor receptor 2 (HER-2) positive patients had higher levels of pDCs than HER-2 (p = 0.040). No relationships were observed with T stage, N stage, Ki67 index, histologic grade, nuclear grade, and lymphovascular invasion. In multiple regression analysis, patients with HER-2 positive breast cancer had higher levels of pDCs than HER-2 negative patients (p = 0.026). Conclusion An increase of pDCs in the peripheral blood of breast cancer patients was observed and patients with HER-2 positive breast cancer had higher levels of circulating pDCs than did HER-2 negative patients. Our results suggest that expression of DCs can differ according to breast cancer subtype and indicate that, with further investigation, DC expression has the possibility of being presented as a prognostic factor.