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The Role of Thymus Preservation in Parathyroid Gland Function And

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The Role of Thymus Preservation in Parathyroid Gland Function And International Journal of Surgery 65 (2019) 1–6 Contents lists available at ScienceDirect International Journal of Surgery journal homepage: www.elsevier.com/locate/ijsu Original Research The role of thymus preservation in parathyroid gland function and surgical T completeness after bilateral central lymph node dissection for papillary thyroid cancer: A randomized controlled study ∗ ∗∗ Wei Lia,1, Bin Wanga,1, Zhi-guo Jiangb, Yun-jie Fenga, Wei Zhanga, , Ming Qiua, a Department of General Surgery of Changzheng Hospital Affiliated to Second Military Medical University, 200003, Shanghai, China b Department of General Surgery of the First People's Hospital, Taizhou, 318000, Zhejiang Province, China ARTICLE INFO ABSTRACT Keywords: Background: The clinical value of thymus preservation during thyroid carcinoma surgery remains unclear. The Thymectomy aim of this study is to explore the role of bilateral thymus preservation in parathyroid glands (PGs) function and Hypoparathyroidism surgical completeness in total thyroidectomy (TT) with bilateral central lymph node dissection (CLND). Central lymph node dissection Materials and methods: Fifty-four consecutive patients who underwent TT and bilateral CLND were assigned to Papillary thyroid cancer the thymus preservation (TP) group (n = 27) and the bilateral thymectomy (BT) group (n = 27). Surgical completeness was evaluated by the number of lymph nodes dissected, serum Tg level and ultrasound findings postoperatively. Results: Incidental parathyroidectomy was more common in the BT group (29.6% vs 7.4%, p = 0.038). Patients in the BT group had higher risks of neuromuscular symptoms (63.0% vs 29.6%, P = 0.014) and transient hy- poparathyroidism (70.4% vs 25.9%, P = 0.001). The incidence of persistent hypoparathyroidism failed to show a significant difference between the TP and BT groups (0 vs 14.8%, P = 0.111). However, those withtransient hypoparathyroidism in the BT group had a lower level of serum PTH at 3 weeks postoperatively (p = 0.001). There was no significant difference in the number of lymph nodes dissected (5.89 ± 3.12 vs 8.56±6.93, P = 0.077) and preablation sTg level (1.82 ± 2.18 vs 1.42 ± 1.56 ng/ml, P = 0.775) between the TP and BT groups. No metastatic lymph nodes were found on sonography at 3 months postoperatively in both groups. Conclusion: Thymus preservation had benefits on protecting PGs and promoting rapid clinical resolution of hypoparathyroidism. It had no effects on oncologic completeness of TT with bilateral CLND. 1. Introduction Boundaries for central neck dissection are defined superiorly by the hyoid bone, inferiorly by the suprasternal notch, laterally by the medial Among all neck compartments, the ipsilateral central neck com- aspect of the carotid sheath, posteriorly by the prevertebral fascia, and partment is involved most frequently in lymph node metastasis of pa- anteriorly by the superficial layer of the deep cervical fascia according pillary thyroid carcinoma (PTC) [1]. Even for cN0 PTCs, lymph node to the 2015 America Thyroid Association (ATA) consensus statement metastases are found in 40–60% of the central lymph nodes after sur- [6]. The upper poles of the thymus as well as the inferior PGs are in- gery [2]. There is consensus on performing central lymph node dis- cluded in the boundaries. section (CLND) in patients with clinical lymph node metastases. How- The thymus and the inferior PGs are both derived from the en- ever, for patients without evidence of lymph node metastases before doderm of pharyngeal pouch III [7] and are located in close proximity surgery, prophylactic neck dissection remains controversial due to the to each other within the paratracheal area of the central neck com- lack of clear data regarding its survival benefit and complications [3]. partment. They share the same blood supply [8]. Thymus preservation Hypoparathyroidism is a major complication when it comes to CLND, during CLND may reduce the risk of PG blood supply injuries or in- which closely correlates with the extent of operation as well as in- cidental removal of the PGs, and thus decrease the prevalence of cidental removal of parathyroid glands (PGs) [4,5]. postoperative hypocalcemia. However, the potential risk of thymic ∗ Corresponding author. Department of General Surgery, The Changzheng Hospital affiliated to the Second Military Medical University, Shanghai, 200003, China. ∗∗ Corresponding author. Department of General Surgery, The Changzheng Hospital affiliated to the Second Military Medical University, Shanghai, 200003, China. E-mail addresses: [email protected] (W. Zhang), [email protected] (M. Qiu). 1 Wei Li and Bin Wang contributed equally to this work and should be considered as co-first authors. https://doi.org/10.1016/j.ijsu.2019.02.013 Received 8 November 2018; Received in revised form 26 January 2019; Accepted 18 February 2019 Available online 26 February 2019 1743-9191/ © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved. W. Li, et al. International Journal of Surgery 65 (2019) 1–6 metastasis makes thymus preservation controversial, despite of its low performed if glands appeared to be devascularized completely. incidence in PTC [9]. Therefore, it is necessary to weigh the benefits against the risks of thymus preservation and determine the optimal 2.4. Outcome measures extent of CLND. Previous retrospective observational studies have been performed “Hypoparathyroidism” was defined as a condition in which calcium comparing bilateral and unilateral thymectomy (upper poles) during or vitamin D supplementation was required to maintain normocalcemia CLND for unilateral differentiated thyroid cancer [10,11]. However, a and serum intact parathyroid hormone (PTH) concentration was less lack of prospective randomized controlled trials has hampered the than 15 pg/ml (range 15–65 pg/mL). Lack of recovery of PTH level to current understanding on the benefits and risks of thymus resection or the normal range within 6 months was defined as “permanent hypo- preservation. With regards to patients with bilateral PTC, whether bi- parathyroidism; ” otherwise, it was defined as “transient hypopar- lateral thymectomy or thymus preservation during bilateral CLND is the athyroidism.” The decreased ratio of PTH was calculated as: (pre- problem that needs to be addressed. In this prospective, randomized operative PTH-postoperative PTH) × 100/preoperative PTH. study, we aimed to compare the outcomes of thymus preservation with Primary outcome measures were function of parathyroid gland (e.g. bilateral thymectomy in order to determine the proper extent of CLND incidence of transient and persistent hypoparathyroidism) and surgical for bilateral PTC. completeness (e.g. number of lymph nodes dissected, thyroglobulin (Tg) and ultrasound findings). The secondary end points were operative 2. Materials and methods duration, hospitalization time and complications (e.g. Vocal cord palsy). The study protocol was approved by our institutional Ethics Committee and written informed consent was obtained from each 2.5. Perioperative management and follow-up participant. This study was registered on the Chinese Clinical Trial Registry (ChiCTR) database and the unique identifying number has All patients underwent preoperative ultrasound, fine needle as- been listed on the title page. The whole work has been reported in line piration biopsy, and direct laryngoscopy which aimed to assess vocal with Consolidated Standards of Reporting Trials (CONSORT) cord motility. Postoperative evaluation of all patients included assess- Guidelines. ments of PTH levels and pathological characteristics (e.g., incidental removed PGs). 2.1. Patients The normal range of PTH levels was 15–65 pg/ml. Patients with a serum calcium of less than 1.90 mmol/L and symptoms of hypo- Patients satisfying the following criteria were recruited: (1) age calcemia (e.g., paresthesia, tetany) took oral calcium carbonate, vi- 18–70 years; (2) preoperatively highly suspected with bilateral papil- tamin D3 chewable tablets (1.2–2.4 g/day), and calcium gluconate lary carcinoma based on ultrasound findings or ultrasound -guided fine (3.6 g/day). needle aspiration cytology; (3) signed informed consent. Patients were Postoperative follow-up was performed by outpatient visits, tele- excluded if they met one or more of the following criteria: (1) contra- phone interview, and written correspondence. Patients were clinically indications for anesthesia such as pregnancy, multiple organ failure, or evaluated, including measurements of neuromuscular symptoms, as mental disease; (2) a history of neck surgery or radiotherapy; (3) con- well as serum calcium and PTH levels, which were measured on 3 comitant Graves disease; (4) preoperative diagnosis of lateral lymph weeks, 3 months and 6 months postoperatively. Moreover, evaluations node metastases based on ultrasound, computed tomography, or fine of serum calcium and PTH levels were no longer needed when these needle aspiration cytology; (5) preoperative hypoparathyroidism or indexes reverted to normal. Thyroid stimulating hormone suppression hypocalcemia; and (6) thymus disease. Between November 2016 and with thyroxine therapy was given to all patients after surgery. Thyroid November 2017, 54 consecutive PTC patients were randomly allocated function test, Tg and TgAb levels were checked on postoperative week to either the TP group (thymus preservation) or the BT group (bilateral 3. Neck ultrasound was performed at 3 months after surgery. For pa- thymectomy).
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