Background. Lymph node metastasis occurs in 20%-50% of patients presenting for initial treatment of papillary thyroid cancer (PTC). The significance of lymph node metastases remains controversial, and the aim of this study is to determine how the lymph node ratio (LNR) may predict the likelihood of disease recurrence. Methods. We conducted a retrospective review of patients undergoing total thyroidectomy for PTC at our institution from 2005 to 2010. A total LNR (positive nodes to total nodes) and central lymph node ratio (cLNR) was calculated. Regression was used to determine a threshold LNR that best predicted recurrence. Multivariate logistic regression then determined the influence of LNR on recurrence while accounting for other known predictors of recurrence. Kaplan-Meier analysis and the log-rank test were used to compare differences in disease-free survival. Results.Of the 217 patients undergoing total thyroidectomy for PTC, 69 patients had concomitant neck dissections. Sixteen (23.2%) patients developed disease recurrence. When disease-free survival functions were compared, we found that patients with a total LNR Ն0.7 (p Ͻ .01) or a cLNR Ն0.86 (p ϭ .04) had significantly worse disease-free survival rates than patients with ratios below these threshold values. Considering other known predictors of recurrence, we found that LNR was significantly associated with recurrence (odds ratio: 19.5, 95% confidence interval: 4.1-22.9; p Ͻ .01). Conclusions. Elevated total LNR and cLNR are strongly associated with recurrence of PTC after initial operation. LNR in PTC is a tool that can be used to determine the likelihood of the patient developing recurrent disease and inform postoperative follow-up. The Oncologist 2013;18:157-162 Implications for Practice: Patients with PTC and lymph node metastases are currently staged according to presence or absence of lymph node metastases in anatomic compartments. The extent of disease in the lymph nodes is not considered in current staging systems. The LNR can be used to further risk-stratify patients with PTC for their risk of recurrence. In the postoperative period, the LNR is helpful in deciding frequency of follow-up, the need for radioactive iodine, or to provide a more informed discussion with the patient regarding the likelihood of recurrence. INTRODUCTIONLymph node metastases occur in 20%-50% of patients presenting for initial treatment of papillary thyroid cancer (PTC) [1,2]. This percentage reaches 90% when considering micrometastatic disease [3]. Presence of lymph node metastases is an independent risk factor for recurrence [4,5], and recurrence can add significant treatment morbidity. Population-based studies have demonstrated that lymph node metastases do carry a small but significant negative effect on disease-specific survival rates [6]. The strength of this association, however, has varied widely in other studies [7,8].When recurrence does occur, it often leads to a second operation that carries a higher complication rate, especially if the recurrence is ...

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Background-Surgical site infections (SSIs) after thyroidectomy are rare but can have significant consequences. Thyroidectomy is a clean case, and the patterns for use of prophylactic antibiotics vary. We hypothesized that patient and operative characteristics may predict a higher risk of SSI, and that SSI are associated with other complications leading to increased resource utilization. Methods-Data from the American College of Surgeons National Surgical Quality Improvement Program dataset for patients who underwent thyroidectomy through cervical incisions from 2005-2011 were included. Bivariate analysis using t-tests and chi-square tests were performed, and variables with P < 0.2 were considered for inclusion in a multivariate logistic regression model. Results-A total of 49,326 patients underwent thyroidectomy from 2005-2011 and 179 (0.36%) had an SSI. On multivariate analysis, the strongest predictors of SSI were operative time (P < 0.001) and wound classification clean-contaminated (odds ratio 6.1; 95% confidence interval, 3.6, 10.3). Preoperative factors associated with SSI on multivariate analysis had lower magnitudes of influence on SSI risk but included obesity, alcohol use, and nonindependent functional status. Patients with SSI were more likely to have a wound dehiscence, renal insufficiency, bleeding requiring transfusion, and return to the operating room on a multivariate model of outcomes. Conclusions-Although rare, SSI after thyroidectomy are associated with other postoperative complications. We have identified preoperative and intraoperative factors that are associated with SSI, and this may help identify high-risk patients who may benefit from selective use of antibiotics.

Background-Twenty-five percent of Medullary Thyroid Cancer (MTC) cases are hereditary. The ideal age for prophylactic thyroidectomy is based upon the specific RET mutation involved. The aim of this study is to determine if such age-appropriate prophylactic thyroidectomy results in improved disease-free survival. Methods-Twenty-eight patients underwent thyroidectomy for hereditary MTC at our institution. Age-appropriate thyroidectomy was defined according to the North American Neuroendocrine Tumor Society (NANETS) guidelines. Patients having age-appropriate surgery (Group 1, n=9) were compared to those having thyroidectomy past the recommended age (Group 2, n=19). Results-The mean age was 13 ± 2 years and 61% were female. Patients in Group 1 were younger than Group 2 (4 ± 1 vs. 17 ± 2 years, p<0.01). There were no significant differences in gender or RET mutation types between these two groups. Group 1 patients were cured with no disease recurrence as compared to Group 2 patients who had a 42% recurrence rate (p=0.05). Subanalysis of Group 2 identified that patients who underwent surgery without evidence of disease did so at a shorter period following the guidelines as compared to those who underwent therapeutic surgery (2 ± 2 vs. 16 ± 2 years, p=0.01) and had longer disease-free survival (100% vs. 27%, p=0.005). Conclusion-Patients with hereditary MTC should undergo age-appropriate thyroidectomy based on RET mutational status to avoid recurrence. Patients who are past the recommended age should have surgery as early as possible in order to improve disease-free survival.

Introduction-A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify pre-operative variables predictive of a more difficult thyroidectomy using the TDS.