Chapter 1 of 5 · Evidence & Research
Volume outcomes
Volume-Outcome Relationships in Thyroid Surgery
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What the experts said
There is a definite increase in pediatric thyroid disease incidence over two decades according to SEER database, including large thyroid nodules not attributable to better screening.
Approximately 4-5% of children have a thyroid nodule, and of those, approximately 30% are malignant.
In adults, thyroid nodules are more prevalent but malignancy rate is lower—an inverse ratio compared to pediatrics.
In pediatric populations, thyroid cancers tend to have more nodal disease, are more multifocal, and are more likely to be metastatic to lung or bone compared to adults.
Predictors of malignancy in pediatric thyroid nodules include male gender, compression symptoms, palpable lymphadenopathy, higher TSH, microcalcifications, indistinct margins, hypochoic pattern, and increased nodular vascularization.
The incidence of differentiated thyroid cancer in hyperfunctioning nodules is upwards of 10 times higher in children than in adults, so general recommendations are to remove hyperfunctioning nodules in pediatric patients.
In 10-40 year follow-ups of pediatric thyroid cancer, there is 98% overall survival, but of deaths that occur, two-thirds are from non-thyroid malignancies, and of those, most patients had received radiation.
A Washington group study of approximately 4000 patients from the National Cancer Database found no difference in 15-20 year outcomes between partial thyroidectomy (ipsilateral thyroidectomy and isthmectomy) and total thyroidectomy for nodules over 1 centimeter.
National Inpatient Sample data on approximately 1200 pediatric patients showed children had higher rates of both general and endocrine-specific complications (recurrent laryngeal nerve injury or hypocalcemia) compared to adult comparison cohorts.
A surgeon doing one thyroidectomy per year compared to a surgeon doing 25 per year is 90% more likely to have a complication.
National Inpatient Sample data on approximately 16,000 adult patients over 10 years showed surgeons performing fewer than 25 thyroidectomies per year have significantly higher additional risk of overall complications compared to high-volume surgeons (>25 cases/year).
In pediatric patients, comparing high-volume (undefined threshold) and low-volume (1-2 cases per year) surgeons, there is nearly a twofold difference in inpatient overall complications.
Only 5% of pediatric surgeons in the National Inpatient Sample were high-volume surgeons, meaning most pediatric surgeons doing thyroid surgery are low-volume surgeons.
Relative risk factors for hypoparathyroidism include nodal dissection (over 2-fold higher risk), total thyroidectomy, Graves' disease operations, and malignancy.
Overall rate of hypoparathyroidism after partial or total thyroidectomy is 5-15%, with most being transient but some permanent.
Among low-volume surgeons, hypoparathyroidism rate is approximately 5-15%, but this goes down to about 2.5% among high-volume surgeons—nearly a fivefold difference.
Patients who underwent total thyroidectomy with central node dissection have much higher rates of recurrent laryngeal nerve palsy and transient or permanent hypocalcemia compared to those without central node dissection.
Relative risk factors for recurrent laryngeal nerve injury include large tumor, non-visualized nerve, malignancy, nodal dissection, and redo operation.
Overall statistics show approximately 0.3-1% risk of permanent recurrent laryngeal nerve injury in pediatric thyroidectomy patients, and 1-6% risk of transient palsy.
Approximately 15% of children presenting with thyroid cancer already have nerve dysfunction at baseline before surgery.
Double-scrubbing (two attendings operating together) can maintain adequate case volume across a surgical group while keeping complication rates very low.
Aggressive parathyroid reimplantation has dramatically dropped hypoparathyroidism rates in the speaker's practice.
When parathyroid glands appear dusky intraoperatively, they should be biopsied; if there is red blood, leave them in place; if there is no red blood, remove and reimplant them.
Reimplanted parathyroid glands take about one month to return to function.
Intact parathyroid hormone (iPTH) should be measured in the recovery room and again at 6 and 8 hours postoperatively; if iPTH is less than 10, start vitamin D and calcium supplementation; if in the 30s, provide temporary supplementation expecting improvement.
Thyroid surgery guidelines have been rewritten four times in the last ten years, indicating rapid evolution of the field.
The 2015 American Thyroid Association guidelines state that ultrasound characteristics of thyroid nodules are important for determining significance, not only size.
The 2015 American Thyroid Association guidelines state that fine needle aspiration (FNA) is an appropriate next step for thyroid nodules but must be done under ultrasound guidance.
The 2015 American Thyroid Association guidelines state there is not enough evidence in pediatrics to suggest that the character of specific thyroid cancer can predict outcomes or which patients should have certain treatments.
The 2015 American Thyroid Association guidelines recommend surgical resection (lobectomy) for any hyperfunctioning nodule, even after controlling hyperthyroidism.
The 2015 American Thyroid Association guidelines state that radioactive iodine ablation is not recommended across the board for low-risk patients (disease confined to thyroid or only incidentally found in surrounding lymph node), in contrast to standard practice for high-risk patients with metastatic disease or multiple bulky nodes.
The 2015 American Thyroid Association guidelines state that children with differentiated thyroid cancer should be taken care of at a center of excellence.