Maisie Shindo

The opioid prescribing practices of physicians are a well-established contribution to the ongoing opioid epidemic.¹ Patient satisfaction with pain control has been thought to be determined by the amount of opioid medication prescribed, a belief that has contributed to generous prescribing habits.² However, recent studies in the head and neck surgical literature have demonstrated that patient satisfaction with care and postoperative pain control is not associated with the amount of opioids prescribed.^3,4

Importance Current guidelines recommend total thyroidectomy for the majority of pediatric thyroid cancer owing to an increased prevalence of multifocality. However, there is a paucity of information on the exact prevalence and risk factors for multifocal disease—knowledge that is critical to improving pediatric thyroid cancer management and outcomes. Objective To determine the prevalence and risk factors for multifocal disease in pediatric patients with papillary thyroid carcinoma (PTC). Design, Setting, and Participants This multicenter retrospective cohort study included patients 18 years or younger who underwent thyroidectomy for PTC from 2010 to 2020 at 3 tertiary pediatric hospitals and 2 tertiary adult and pediatric hospitals in the US. Main Outcomes and Measures Demographic and clinical variables, including age, family history of thyroid cancer, autoimmune thyroiditis, prior radiation exposure, cancer predisposition syndrome, tumor size, tumor and nodal stage, PTC pathologic variant, and preoperative imaging, were assessed for association with presence of any multifocal, unilateral multifocal, and bilateral multifocal disease using multiple logistic regression analyses. Least absolute shrinkage and selection operator analysis was performed to develop a model of variables that may predict multifocal disease. Results Of 212 patients, the mean age was 14.1 years, with 23 patients 10 years or younger; 173 (82%) patients were female. Any multifocal disease was present in 98 (46%) patients, with bilateral multifocal disease in 73 (34%). Bilateral multifocal disease was more accurately predicted on preoperative imaging than unilateral multifocal disease (48 of 73 [66%] patients vs 9 of 25 [36%] patients). Being 10 years or younger, T3 tumor stage, and N1b nodal stage were identified as predictors for multifocal and bilateral multifocal disease. Conclusions and Relevance This large, multicenter cohort study demonstrated a high prevalence of multifocal disease in pediatric patients with PTC. Additionally, several potential predictors of multifocal disease, including age and advanced T and N stages, were identified. These risk factors and the high prevalence of multifocal disease should be considered when weighing the risks and benefits of surgical management options in pediatric patients with PTC.

The epidemic of opioid abuse has continued to plague the United States. The rate of drug overdose deaths increased from 6.1 per 100 000 standard population in 1999 to 16.3 per 100 000 in 2015, with an overall mean increase of 5.5% per year.¹ According to the Centers for Disease Control and Prevention, approximately 64 000 deaths in the United States were due to opioid overdose in 2016.²

Introduction: This video is intended as an introductory review of key surgical landmarks for performance of a safe and thorough selective neck lymph node dissection for metastatic papillary thyroid carcinoma. Case: The patient is an 11-year-old boy with metastatic papillary thyroid cancer. His initial diagnosis was made on fine needle aspiration of a palpable right thyroid mass. Preoperative computed tomography scan demonstrated extensive bilateral cervical lymphadenopathy and pulmonary metastatic disease. The patient underwent attempted total thyroidectomy, which was aborted due to extensive locally invasive disease. He was then referred to our Thyroid and Parathyroid Center, a tertiary referral center for complex thyroid cancer surgery. A comprehensive preoperative and multidisciplinary evaluation was performed. A completion thyroidectomy was performed with comprehensive bilateral central neck dissection (performed by Mira Milas), followed by staged bilateral neck dissections. This video highlights all the critical cervical nerves exposed during the left selective neck dissection (performed by Maisie Shindo) with focus on safe operative steps of identification and illustration of anatomic relationships. Conclusions: Surgery remains the primary modality for treatment of papillary thyroid carcinoma with lymph node dissection as the mainstay in treatment for clinically evident cervical lymph node metastases. Surgeons performing this procedure should be familiar with the critical structures in the neck and strategies to avoid iatrogenic injury. In addition, compartment-based¹ en-bloc removal of lymph node groups, as shown here, is favored over isolated “berry picking” of grossly involved nodes, with studies suggesting improvement in the mortality rate according to the American Thyroid Association guidelines.² To be presented at the ACS meeting in Chicago on October 7, 2015. No competing financial interests exist. Runtime of video: 8 mins 24 secs

Background: Invasive differentiated thyroid cancer (DTC) is relatively frequent, yet there is a paucity of specific guidelines devoted to its management. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to provide clinical consensus statements based on review of the literature, synthesized with the expert opinion of the group.Methods: An expert panel, selected from membership of the AHNS, constructed the manuscript and recommendations for management of DTC with invasion of recurrent laryngeal nerve, trachea, esophagus, larynx, and major vessels based on current best evidence. A Modified Delphi survey was then constructed by another expert panelist utilizing 9 anchor points, 1 = strongly disagree to 9 = strongly agree. Results of the survey were utilized to determine which statements achieved consensus, near‐consensus, or non‐consensus.Results: After endorsement by the AHNS Endocrine Committee and Quality of Care Committee, it received final approval from the AHNS Council. © 2014 Wiley Periodicals, Inc. Head Neck, 36: 1379–1390, 2014

Central lymph node dissection (CLND) in papillary thyroid carcinoma (PTC) for subclinical nodal disease has been a topic of great controversy during the past decade. The incidence of occult cervical lymph node metastasis is high, with estimates of as much as 60% of affected patients having node-positive disease.1 Despite this prevalence, PTC carries anexcellent survival rate. However, nodal recurrence has been shown to be associated with a higher recurrence rate of as much as 30% in 1 series.2,3 Recurrences usually manifest as cervical nodal metastasis, and when metastasis occurs in the central neck, treatment can result in complications. Quiz Ref IDReoperation for recurrent disease in the central neck has a high risk of laryngeal nerve paralysis and hypocalcemia. Repetitive radioactive iodine treatments for the disease may predispose the patient to developing secondary malignant neoplasms.