Xiaowei Peng

Background: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) offers a scarless alternative to conventional thyroidectomy. Although established selection criteria exist, clinical scenarios exceeding these parameters are increasingly encountered in practice, yet evidence regarding their safety and feasibility remains limited. This study aimed to systematically review published indications for TOETVA and to preliminarily explore its feasibility in patients with conditions beyond conventional criteria through a case series analysis. Methods: A comprehensive literature review was conducted across PubMed, Web of Science, and the Cochrane Library for studies published up to July 2026, yielding 800 records, of which 131 studies met the inclusion criteria and were analyzed. Articles reporting specific inclusion criteria for TOETVA were analyzed, including thyroid size, gland volume, and maximum resected benign or malignant nodule sizes. In addition, a retrospective case series was performed involving seven patients who underwent TOETVA at a tertiary center between January 2021 and February 2024. Indications included bulky thyroid glands, large benign nodules, intrathyroidal T3a papillary thyroid carcinoma (PTC), and PTC with concomitant neck masses. Surgical feasibility, perioperative outcomes, complications, and recurrence were evaluated. Results: A total of 131 studies met the inclusion criteria. Most reports limited thyroid diameter to ≤10 cm and gland volume to ≤45–50 mL. For benign nodules, the most frequent upper limit was ≤6 cm, while for malignant tumors, ≤2 cm was the most common criterion. The case series included one bulky thyroid gland, one large benign nodule, two intrathyroidal T3a PTCs, and three PTCs with concomitant neck masses. All operations were successfully completed via TOETVA without conversion to open surgery. The mean operative time was 196 ± 25.3 min, mean drainage volume was 104 ± 67 mL, and mean postoperative hospital stay was 3.14 ± 1.68 days. One patient experienced transient hypoparathyroidism, and no recurrences or major complications were observed during a median follow-up of 34 months (range, 25–58 months). Conclusions: TOETVA is feasible for carefully selected patients beyond standard indications strictly within highly experienced centers, following thorough preoperative imaging and multidisciplinary team (MDT) evaluation. However, we strongly caution against a generalized expansion of indications. In these complex cases, oncologic safety must always be prioritized over cosmetic benefits, and further multicenter evidence is required to confirm long-term outcomes.

Objective To address the lack of guidance for operating the non-dominant side in TOETVA by assessing whether non-dominant-hand TOETVA on the non-dominant side (left hand–left lobe) is a feasible strategy with similar surgical outcomes compared with the conventional dominant-hand approach (right hand–right lobe). Methods This is a single-center, single-surgeon retrospective cohort. Consecutive unilateral TOETVA cases (August 2016–August 2020) were included. Patients were grouped as NDH-TOETVA (left hand on the left lobe) or DH-TOETVA (right hand on the right lobe). Learning curves were segmented using cumulative sum (CUSUM) of operative time into Phase I (initial), Phase II (adaptation), and Phase III (mastery). Phase III outcomes were compared after 1:1 propensity score matching (PSM) on key covariates. Results CUSUM identified distinct phase boundaries: DH-TOETVA Phase I cases 1–13, Phase II 14–54, Phase III ≥ 55; NDH-TOETVA Phase I 1–17, Phase II 18–37, and Phase III ≥ 38. After PSM in Phase III, 176 patients were analyzed (NDH 88 cases, DH 88 cases). Post-match baseline characteristics were balanced. There were no significant differences between NDH and DH in operative time, estimated blood loss, central neck lymph nodes retrieved/positive, length of stay, postoperative drainage, and complications (P > 0.05). Conclusions Hand-side matching is a feasible strategy with compared surgical outcomes in TOETVA. Findings support incorporating this strategy and bilateral-hand training into standardized practice with phase-based, objective assessment. Trial registration number Chinese Clinical Trial Registry (UIN: ChiCTR2500097005, https://www.chictr.org.cn), 2025.2.11.

Objective: With the growing application of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for papillary thyroid carcinoma (PTC), understanding patient preferences is critical to improving communication and supporting informed decision-making. This study aimed to identify key factors influencing surgical choices. Method: A discrete choice experiment was conducted with patients diagnosed with PTC who were scheduled for thyroidectomy. Participants evaluated hypothetical surgical scenarios varying in six attributes: incision location, incision size, recurrence rate, operative duration, complication rate, and cost. Preferences and willingness to pay (WTP) were analyzed using a mixed logit model. Results: A total of 271 patients were included in this study. Patients demonstrated a strong preference for surgical options with lower recurrence rates and scarless approaches. They were willing to pay an additional ¥201,409.60 to reduce the recurrence rate from 10% to 1% and ¥19,141.14 to change the surgical scar location from external to internal. The recurrence rate emerged as the most crucial non-financial factor (β = 8.18, P < 0.001, 95%), followed by incision location (β = 0.78, P < 0.001), and complication rate (β = 0.25, P = 0.030). Demographic factors such as gender, age, education level, marital status, and income exhibited notable differences in postoperative cosmetic concerns. Conclusion: Recurrence risk is the primary driver of surgical preference in PTC patients, followed by cosmetic outcomes. Additionally, postoperative cosmetic concerns varied across different demographic groups. These findings highlight the need for surgeons to consider patient-specific values during preoperative consultations to enhance shared decision-making. Clinical Trial Registration: https://www.chictr.org.cn/showproj.html?proj=191809 , identifier ChiCTR2300069048.

Objective: To overcome certain anatomical limitations of transoral vestibular thyroidectomy, we introduced endoscopic thyroidectomy via the submental approach. During subsequent clinical practice, additional advantages of the submental approach were identified, further enhancing its feasibility and clinical applicability. This study aimed to evaluate the safety, efficacy, and postoperative outcomes of this technique in thyroid surgery. Methods: We retrospectively analyzed patients who underwent endoscopic thyroidectomy via the submental approach at Hunan Cancer Hospital between March and September 2023. Perioperative outcomes, complications, and postoperative quality of life were assessed using validated clinical indicators and the Thyroid Cancer-Specific Quality of Life questionnaire. Results: A total of 50 patients (27 males, 23 females; mean age 41.66 ± 9.70 years) were included. The mean operative time was 93.61 ± 21.78 minutes for unilateral thyroidectomy and 137.39 ± 27.76 minutes for total thyroidectomy. The mean pain score at 48 hours postoperatively was 1.56 ± 0.61, and the mean postoperative hospital stay was 2.84 ± 0.81 days. The mean aesthetic satisfaction score was 4.28 ± 0.67 (1–5, with higher scores indicating better satisfaction). The mean quality-of-life score was 10.23 ± 5.33 (0–130, with lower scores indicating better quality of life). No surgical site infections occurred. Transient hypoparathyroidism occurred in 14.8% of patients, and transient recurrent laryngeal nerve palsy occurred in 4.00%. The mean follow-up duration was 22 months, and no cases of recurrence or distant metastasis were observed during the follow-up period. Conclusions: Endoscopic thyroidectomy via the submental approach effectively balances cosmetic outcomes, surgical trauma, oncological integrity, and surgical feasibility, providing a promising alternative for endoscopic thyroidectomy. Further prospective, multicenter studies are needed to validate its long-term safety and broader clinical applicability. Clinical trial registration: https://www.chictr.org.cn , identifier ChiCTR2400089684.

Background: In this study, a novel lymph node tracer—mitoxantrone hydrochloride injection for tracing (MHI)—was intraoperatively administered into suspected metastatic lateral cervical lymph nodes of patients with papillary thyroid carcinoma (PTC), aiming to evaluate its staining efficacy and clinical value in enhancing the completeness of lateral neck dissection (LND). Methods: A prospective controlled study was conducted at Hunan Cancer Hospital between December 2023 and May 2024, enrolling a total of 67 patients diagnosed with thyroid carcinoma. After informed consent, patients were allocated to either MHI or methylene blue group. Subjects were divided into an MHI group ( n = 42) and a methylene blue group ( n = 25). All patients underwent LND. Results: The results demonstrated no statistically significant differences between the two groups in terms of operative time, total number of lymph nodes dissected, cervical drainage volume, or postoperative length of hospital stay ( P > 0.05). However, the MHI group exhibited superior staining of suspected metastatic lymph nodes, with a greater number of metastatic lymph nodes and a higher positive ratio compared to the methylene blue group ( P < 0.05). Conclusion: MHI causes minimal tissue contamination and can effectively enhance the thoroughness of LND in patients with thyroid carcinoma, demonstrating high clinical application value.

Given the scarcity of studies predicting iodine-131 treatment failure based on clinicopathological factors, this study aimed to determine whether clinicopathological features can predict iodine-131 treatment failure in differentiated thyroid carcinoma (DTC) patients. A total of 182 patients were analyzed, including 114 with favorable outcomes and 68 with resistance or poor outcomes. Patients were split into a training set (122 patients) and a validation set (60 patients). Logistic regression identified the number of lateral neck lymph node metastases (P = 0.001) and pre-radioactive iodine therapy serum thyroglobulin levels (P = 0.001) as independent predictors of treatment failure. The predictive model, visualized via a nomogram, achieved area under curves (AUCs) of 0.838 (95% CI, 0.759–0.917) and 0.766 (95% CI, 0.626–0.905) in the training and validation sets, respectively. Calibration curves showed good agreement between predicted and observed outcomes, and decision curve analysis confirmed the model’s clinical utility. Subgroup analyses yielded AUCs of 0.777 (95% CI, 0.648–0.906), 0.745 (95% CI, 0.646–0.843), 0.734 (95% CI, 0.649–0.820), and 0.911 (95% CI, 0.769–0.999) for male, female, age < 55, and age ≥ 55 groups, respectively. This model effectively predicts iodine-131 treatment failure risk in DTC patients, providing valuable information for clinical decision-making.

Purpose Fibroblast activation protein (FAP)-targeted PET/CT has emerged as a promising tool for visualizing tumor stroma. This study aimed to validate the diagnostic efficacy of [¹⁸F]AlF-NOTA-FAPI-04 PET/CT in detecting subclinical metastases in recurrent differentiated thyroid cancer (DTC), with direct comparison to [¹⁸F]FDG PET/CT. Methods Twenty-three DTC participants with biochemical recurrence (suppressed thyroglobulin [Tg] ≥ 1 ng/mL or Tg antibodies [Tg-Ab] > 115 IU/mL) underwent [¹⁸F]AlF-NOTA-FAPI-04 PET/CT, including 16 who underwent paired [¹⁸F]FDG scans. Lesion classification followed histopathology or 15.5-month clinical follow-up (median, 8–32 months). Results [¹⁸F]AlF-NOTA-FAPI-04 PET/CT demonstrated significantly higher lesion-level sensitivity (75% vs. 13%, P = 0.002) and accuracy (80% vs. 27%, P < 0.001) than [¹⁸F]FDG. Participant-level sensitivity reached 100% (7/7 vs. 14% [1/7], P = 0.003). Notably, 7 cervical lymph node metastases (mean diameter 5.9 ± 1.4 mm) were detected exclusively by FAPI imaging. Conclusion [¹⁸F]AlF-NOTA-FAPI-04 PET/CT exhibits superior diagnostic performance over [¹⁸F]FDG PET/CT in detecting small metastatic lesions in recurrent DTC, potentially enabling earlier intervention and improved patient management.

With the increasing popularity of minimally invasive techniques in thyroid surgery, the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has garnered significant attention. This study aimed to compare the impact of different distances between the observation and operation ports in TOETVA on clinical treatment outcomes. Ninety patients with papillary thyroid carcinoma were retrospectively analyzed. Based on the distance between the observation and operation ports, they were divided into three groups: Group A (2.3–2.7 cm), Group B (less than 2.3 cm), and Group C (more than 2.7 cm). All three groups underwent TOETVA performed by the same surgical team. Operation time, blood loss, postoperative hospital stay, drainage volume, retrieved and metastatic central lymph nodes, postoperative complications, and tumor recurrence were compared among the groups. There were no demographic differences among the three groups. Compared to Groups B and C, patients in Group A had significantly shorter operation times, lower postoperative drainage volumes, and shorter postoperative hospital stays (p < 0.05). There were no significant differences in bleeding amount, retrieved and metastatic central lymph nodes, or incidence of complications among the groups. No postoperative recurrences were observed in any patient. In TOETVA, the best surgical outcomes were achieved when the distance between the observation and operation ports was approximately 2.5 cm (2.3–2.7 cm). This configuration ensures smooth surgical operations and facilitates postoperative rehabilitation, making it worthy of further clinical promotion.

The management of papillary thyroid carcinoma (PTC) concurrent with Hashimoto’s thyroiditis (HT) lacks standardized guidelines, especially concerning surgical strategies. This study aimed to compare unilateral thyroidectomy (UT) with total thyroidectomy (TT) in PTC-HT patients to optimize clinical management and improve postoperative outcomes. This retrospective study included PTC-HT patients undergoing thyroid surgery at a tertiary academic medical institution from January 2018 to August 2023. The patients were grouped according to the quartiles of preoperative thyroid peroxidase antibody (TPOAB) levels at the last follow-up. Additionally, patients were divided into UT and TT groups, with propensity score matching (PSM) to ensure comparability. Patients were also stratified by TPOAB levels (L: 100–400, M: 400–1000, H: >1000). Patient-reported outcomes (PROMs), including quality of life and fatigue, were compared between UT and TT groups within each TPOAB subgroup (ΔPROMs = UT-TT). 246 patients were included. Those with higher TPOAB levels at the last follow-up reported increased physical fatigue scores. After PSM, there were no significant demographic differences between UT and TT groups. During a median follow-up of 16 months for UT and 20 months for TT, no recurrence or metastasis occurred. Compared to the UT group, the TT group exhibited lower TPOAB levels at the last follow-up (65.7 ± 78 vs. 374.6 ± 331.9, p < 0.001), and lower physical fatigue scores (3.6 ± 2.5 vs. 4.5 ± 2.8, p = 0.039). However, TT was associated with a higher incidence of transient hypoparathyroidism (7.8% vs. 1.1%, p = 0.030). Stratified analysis by preoperative TPOAB levels revealed significant differences in ΔPROMs (Physical fatigue) between L and H groups (0.2 ± 3.5 vs. 4.6 ± 2, p = 0.004) and between M and H groups (0.6 ± 4.5 vs. 4.6 ± 2, p = 0.037). ΔPROMs (Mental fatigue) also significantly differed between L and H groups (0 ± 1.8 vs. 1.6 ± 0.9, p = 0.026). For PTC-HT patients, particularly those with high preoperative TPOAB levels, TT offers advantages in alleviating fatigue symptoms but carries a higher risk of complications. Therefore, clinical decision-making should consider patient-specific factors, particularly preoperative TPOAB levels, to determine the optimal surgical approach. Trial registration: Chinese Clinical Trial Registry. ID ChiCTR2300069240.