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Various aspects of hemithyroidectomy: Towards individualized treatment
Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Linköping.
2024 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

There are mainly two indications in patients with enlarged thyroid for which a hemithyroidectomy is recommended: (1) surgery as a therapeutic procedure to improve compression symptoms and (2) surgery as a diagnostic procedure to confirm or rule out thyroid malignancy. This thesis evaluates which patients benefit more from hemithyroidectomy and examines the patients' perspectives, which can provide knowledge that can be implemented in meetings with patients.  

Paper I was a preclinical study of fine-needle aspiration cytology (FNAC) from the thyroid gland. The study evaluated if the addition of a molecular BRAF-V600E mutation analysis could detect more papillary thyroid cancers in the palpation-guided FNAC group. The results showed that adding BRAF-V600E mutation analysis might significantly increase the proportion of papillary thyroid cancers diagnosed preoperatively in the palpation-guided FNAC group.  

Paper II was a retrospective cohort study from a well-established Scandinavian quality register (SQRTPA). Retrospective data for two different hemithyroidectomy indications were collected, to exclude malignancy or as a therapeutic procedure. The study showed that the excised thyroid weight was an independent risk factor for bleeding, and permanent recurrent laryngeal nerve paresis was less common in the excluding malignancy group.  

Paper III was a prospective cohort study of patients with compressive symptoms who underwent hemithyroidectomy due to an enlarged thyroid. Seventy-two patients filled in four different questionnaires before and after hemithyroidectomy and objective measurements of the enlarged thyroid were registered before the operation. Most of the patients benefited from hemithyroidectomy, however, many patients had voice impairments 6 weeks after the operation. No correlation was found between the symptom changes and the preoperative measurements of the thyroid lobe.

Paper IV was a qualitative interview study on 16 patients with compression symptoms from an enlarged thyroid who underwent a hemithyroidectomy. The data were analysed using conventional content analysis. The analysis revealed two main categories. Patients experienced postoperative symptoms that affected their daily life and postoperative symptoms that made the patients develop coping strategies. A subcategory showed that the patients had concerns about the future.  

This thesis reinforces that a successful choice of hemithyroidectomy begins with a well-informed patient and professional counselling based on the patient's condition and preferences. A holistic perspective of the patients is central for individualized treatment. 

Abstract [sv]

Knölar i sköldkörteln är vanliga. Tryckbesvär mot luftstrupe eller matstrupe eller en synlig knöl på halsen är vanliga anledningar till att patienter söker vård. Utredningen innefattar anamnes, klinisk undersökning och ultraljudsundersökning av patienten. Om utredningen inte ger några misstankar om att knölen är elakartad, men tryckbesvären är uttalade kan hemityreoidektomi rekommenderas. Detta innebär en kirurgisk borttagning av halva sköldkörteln, i syfte att minska symtom. Vid misstanke om malignitet kan finnålsbiopsi göras, för att utesluta eller bekräfta malignitet. Punktionsmaterialen bedöms av en cytolog. Om cellformationerna anger låg misstanke om malignitet rekommenderas patienten hemityreoidektomi för att säkerställa diagnosen. Vid hög misstanke om malignitet rekommenderas hel borttagning av tyreoidea. Komplikationer är en risk vid kirurgin. Denna avhandling utvärderar vilka patienter som har mer nytta av att opereras med hemityreoidektomi samt undersöker patientperspektivet, vilket kan medföra kunskap som kan omsättas i mötet med patienterna.  

Delstudie I är en preklinisk studie av finnålsaspirationscytologi (FNAC) från sköldkörteln. Två grupper av patienter undersöktes. Den ena gruppen utreddes med palpationsledda FNAC och den andra gruppen med ultraljudsledda FNAC. Studien utvärderar om tillägget av en molekylär BRAF-V600E mutationsanalys kan upptäcka fler papillär sköldkörtelcancer i den palpationsledda FNAC-gruppen. Studien visar att tillägget av BRAF-V600E mutationsanalys kan avsevärt öka andelen preoperativt diagnostiserad cancer i den palpationsledda FNAC-gruppen.

Delstudie II är en retrospektiv studie från ett väletablerat skandinaviskt kvalitetsregister, Scandinavian Quality Register for Thyroid, Parathyroid, and Adrenal Surgery (SQRTPA). När en hemityreoidektomi planeras finns huvudsakligen två indikationer. En indikation är kirurgi som ett terapeutiskt ingrepp för att förbättra trycksymtom från en förstorad sköldkörtel och en indikation är kirurgi som diagnostiskt ingrepp för att bekräfta eller utesluta malignitet i sköldkörteln. Retrospektiva data om dessa två grupper samlades in och analyserades avseende skillnader i komplikationsfrekvensen för blödningar, infektioner och avseende pares i stämbandsnerven. Resultaten visar att den opererade sköldkörtelns vikt var en oberoende riskfaktor för blödning. Bestående skador (6–12 månader) efter operationen i stämbands-nerven var mindre vanliga i gruppen som opererades i diagnostiskt syfte än hos de som opererades för att minska trycksymtom.  

Delstudie III är en prospektiv studie som inkluderat patienter med trycksymtom från halsen som opererats med hemityreoidektomi på grund av förstorad sköldkörtel. Studien syftade till att utvärdera patientens symtomförändringar i det tidiga förloppet (6 veckor) efter hemityreoidektomi.  Studien utvärderade också om de objektiva måtten på den förstorade sköldkörteln korrelerade med symtomförändringarna preoperativt eller postoperativt. Sjuttiotvå patienter uppfyllde inklusionskriterierna och fyllde i fyra olika frågeformulär före och efter hemityreoidektomi. Resultaten visar att de flesta patienterna gynnas av hemityreoidektomi, men en majoritet av patienterna led av röstförändringar sex veckor efter operationen. Inget samband hittades mellan symtomförändringarna och de preoperativa sköldkörtellobsmätningarna. Delstudie IV är en kvalitativ intervjustudie där patienterna i studien även ingår i Delstudie III. Sexton patienter med trycksymtom från förstorad sköldkörtel som opererades med hemityreoidektomi intervjuades tre veckor efter operationen. Data analyserades med konventionell innehållsanalys. Resultatet visade att patienter upplevde postoperativa symtom som påverkade deras dagliga liv och de postoperativa symtomen fick patienterna att utveckla anpassningsstrategier samt att patienterna upplevde oro för bestående komplikationer i framtiden.  

Sammanfattningsvis uppvisar denna avhandling att ett framgångsrikt val av hemityreoidektomi börjar med en välinformerad patient och professionell rådgivning utifrån patientens förutsättningar och preferenser. Ett holistiskt patientperspektiv är centralt för en individualiserad behandling.   

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2024. , p. 57
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1929
National Category
Surgery
Identifiers
URN: urn:nbn:se:liu:diva-208071DOI: 10.3384/9789180757393ISBN: 9789180757386 (print)ISBN: 9789180757393 (electronic)OAI: oai:DiVA.org:liu-208071DiVA, id: diva2:1902464
Public defence
2024-11-01, Belladonna Hall, building 511/ 10th floor, Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Note

2024-10-01: ISBN (PDF) has been added in the E-version.

Available from: 2024-10-01 Created: 2024-10-01 Last updated: 2024-10-01Bibliographically approved
List of papers
1. Increased diagnostic sensitivity of palpation-guided thyroid nodule fine-needle aspiration cytology by BRAF V600E-mutation analysis
Open this publication in new window or tab >>Increased diagnostic sensitivity of palpation-guided thyroid nodule fine-needle aspiration cytology by BRAF V600E-mutation analysis
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2021 (English)In: The journal of pathology. Clinical research, ISSN 2056-4538, Vol. 7, no 6, p. 556-564Article in journal (Refereed) Published
Abstract [en]

Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer and its incidence is increasing. Preoperative diagnosis is warranted in order to avoid two-stage procedures that are associated with additional costs and higher radioactive iodine remnant uptake. In the setting of thyroid cancer, somatic BRAF V600E-mutations are highly specific for PTC and can be analyzed in aspirates from fine-needle aspiration cytology (FNAC). The gold standard to perform FNAC is ultrasound guidance. Here, we analyze whether adding BRAF V600E-mutation analysis could be of value in palpation-guided FNACs. A total of 430 consecutive patients were included. Ultrasound-guided FNACs were performed in 251 patients and 179 patients underwent palpation-guided FNACs. BRAF V600E-mutation analysis was performed using two methods, an allele-specific polymerase chain reaction (PCR) analyzed by capillary gel electrophoresis (PCR/Qiaxcel), and a droplet digital PCR (ddPCR) assay. A total of 80 patients underwent surgery, and histology revealed 25 patients to have PTC. Of the 25 PTCs, 23 (92%) showed a BRAF V600E-mutation. Both mutation analysis methods (PCR/Qiaxcel and ddPCR) produced concordant results. In the ultrasound-guided group, the preoperative diagnostic sensitivity of FNAC using the Bethesda classification alone was very high and additional BRAF V600E-mutation analysis added little to the preoperative diagnostic sensitivity. By contrast, in the palpation-guided group, by adding BRAF V600E-mutation analysis, eight instead of four patients were diagnosed of having PTC. This increase in the diagnostic sensitivity was statistically significant (p < 0.05). The costs per sample were as low as 62 USD (PCR/Qiaxcel and ddPCR) and 35 USD (PCR/Qiaxcel only). Ultrasound-guided FNAC should be aimed for when dealing with thyroid nodules. However, if palpation-guided FNAC cannot be avoided or may be required due to resource utilization, adding BRAF V600E-mutation analysis using the methods described in this study might significantly increase the proportion of preoperatively diagnosed PTCs. The additional costs can be considered very reasonable.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2021
Keywords
papillary thyroid carcinoma; BRAF; mutation analysis; ultrasound-guided; palpation-guided; fine-needle aspiration cytology; FNAC
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-180109 (URN)10.1002/cjp2.231 (DOI)000665025100001 ()34156770 (PubMedID)
Note

Funding Agencies|Medical Research Council of Southeast SwedenUK Research & Innovation (UKRI)Medical Research Council UK (MRC) [FORSS-648671, FORSS-861891]

Available from: 2021-10-08 Created: 2021-10-08 Last updated: 2024-10-01
2. Hemithyroidectomy, does the indication influence the outcome?
Open this publication in new window or tab >>Hemithyroidectomy, does the indication influence the outcome?
2024 (English)In: Langenbeck's archives of surgery (Print), ISSN 1435-2443, E-ISSN 1435-2451, Vol. 409, no 1, article id 1Article in journal (Refereed) Published
Abstract [en]

PurposeHemithyroidectomies are mainly performed for two indications, either therapeutically to relieve compression symptoms or diagnostically for suspicious nodule(s). In case of the latter, one could consider the approach to be rather extensive since the majority of patients have no symptoms and will have benign disease. The aim of this study is to investigate the complication rates of diagnostic hemithyroidectomy and to compare it with the complication rates of compressive symptoms hemithyroidectomy.MethodsData from patients who had undergone hemithyroidectomy either for compression symptoms or for excluding malignancy were extracted from a well-established Scandinavian quality register (SQRTPA). The following complications were analyzed: bleedings, wound infections, and paresis of the recurrent laryngeal nerve (RLN). Risk factors for these complications were examined by univariable and multivariable logistic regression.ResultsA total of 9677 patients were included, 3871 (40%) underwent surgery to exclude malignancy and 5806 (60%) due to compression symptoms. In the multivariable analysis, the totally excised thyroid weight was an independent risk factor for bleeding. Permanent (6-12 months after the operation) RLN paresis were less common in the excluding malignancy group (p = 0.03).ConclusionA range of factors interfere and contribute to bleeding, wound infections, and RLN paresis after hemithyroidectomy. In this observational study based on a Scandinavian quality register, the indication "excluding malignancy" for hemithyroidectomy is associated with less permanent RLN paresis than the indication "compression symptoms." Thus, patients undergoing diagnostic hemithyroidectomy can be reassured that this procedure is a safe surgical procedure and does not entail an unjustified risk.

Place, publisher, year, edition, pages
SPRINGER, 2024
Keywords
Thyroid gland; Hemithyroidectomy; Register study; Complications
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-199674 (URN)10.1007/s00423-023-03168-w (DOI)001115580200001 ()38062331 (PubMedID)
Available from: 2023-12-18 Created: 2023-12-18 Last updated: 2024-10-01
3. Patient Experiences of Symptoms and Coping Strategies in the Early Postoperative Phase Following Hemithyroidectomy: A Qualitative Interview Study
Open this publication in new window or tab >>Patient Experiences of Symptoms and Coping Strategies in the Early Postoperative Phase Following Hemithyroidectomy: A Qualitative Interview Study
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2024 (English)In: JOURNAL OF PATIENT EXPERIENCE, ISSN 2374-3743, Vol. 11, article id 23743735241273580Article in journal (Refereed) Published
Abstract [en]

The aim was to explore patients' early experiences of symptoms after hemithyroidectomy and how these symptoms influenced their daily lives. An inductive explorative qualitative research design was performed. Sixteen patients from two hospitals were interviewed between two-three weeks after the surgery. All the patients experienced compression symptoms before the surgery. The study was analyzed with conventional manifest content analysis. The inductive analysis yielded two main categories and one subcategory. The two main categories were: Early postoperative symptoms that caused disadvantage in daily life and Early postoperative symptoms and coping strategies. The subcategory was: Early postoperative experiences of concerns about the future. Key points: 1. Patients experienced early postoperative symptoms that affected their lives in multiple levels, making them develop coping strategies and awaking concerns about remaining symptoms in the future. 2. The effect of hemithyroidectomy influenced patients' daily life in the early postoperative phase considerably. 3. The study shows that tailored preoperative patient information is important. The findings may guide professionals to tailored preoperative information to optimize the care for this patient group.

Place, publisher, year, edition, pages
SAGE PUBLICATIONS INC, 2024
Keywords
thyroid surgery; postoperative symptoms; hemithyroidectomy; qualitative interviews; content analysis
National Category
Nursing
Identifiers
urn:nbn:se:liu:diva-207248 (URN)10.1177/23743735241273580 (DOI)001290375700001 ()39139704 (PubMedID)
Available from: 2024-09-05 Created: 2024-09-05 Last updated: 2024-10-01

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