Lisa A. Orloff, MD, FACS, FACE

All Publications

• Factors Associated With Psychological Distress Among Thyroid Cancer Patients. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Lin, M. E., Wei, E. X., Finegersh, A., Orloff, L. A., Noel, J. E., Chen, M. M. 2024

  Abstract

  OBJECTIVE: To assess the prevalence of psychological distress (PD) among thyroid cancer patients (TCPs) and identify clinical, demographic, and socioeconomic factors associated with PD.STUDY DESIGN: Retrospective population-based cohort study.SETTING: 2016 to 2018 National Health Interview Survey.METHODS: Adults with cancer were included. The primary outcome measure was moderate-to-severe psychological distress (MSPD), defined as a respondent score ≥5 on the validated K6 Psychological Distress Scale. chi2 tests were used to assess differences in MSPD by cancer type. Weighted multivariable logistic regression was used to elucidate factors associated with MSPD among TCPs.RESULTS: The majority of TCPs (n=684,674) were white (75.4%), female (78.5%), and on average 55.65 years old (SD=13.2). 28.4% reported MSPD. On weighted analysis, TCPs were more likely to have MSPD than prostate (14.9%, P<.001), bladder (16.4%, P=.011), and nonmelanoma skin cancer (16.3%, P<.001) patients but less likely than pancreatic cancer (30.0%, P=.030) patients. TCPs who were older when surveyed (odds ratio [OR], 0.93; 95% confidence interval [CI, 0.88-0.98), previously drank alcohol (OR, 0.23; 95% CI, 0.06-0.91), and saw a general physician (GP) in the past year (OR, 0.14; 95% CI, 0.03-0.56) were less likely to have MSPD. Female sex (OR, 8.12; 95% CI, 1.61-40.89), increased number of medical comorbidities (OR, 1.46; 95% CI, 1.00-2.14), and functional limitations (OR, 4.55; 95% CI, 1.33-15.74) were associated with increased likelihood of MSPD.CONCLUSION: Nearly 30% of TCPs have MSPD, especially younger patients who do not regularly see GPs. Future work to identify the most at-risk patients is needed to improve prevention and develop meaningful psychosocial interventions.

  View details for DOI 10.1002/ohn.1051

  View details for PubMedID 39501654

• Comorbid Depression in Patients With Head and Neck Cancer Compared With Other Cancers. JAMA otolaryngology-- head & neck surgery Martinez, M. C., Finegersh, A., Baik, F. M., Holsinger, F. C., Starmer, H. M., Orloff, L. A., Sunwoo, J. B., Sirjani, D., Divi, V., Chen, M. M. 2024

  Abstract

  Depression is more prevalent among individuals with cancer than in the general population and is correlated with increased mortality in patients with head and neck cancer (HNC) in particular.To compare the prevalence of depression between patients with HNC and patients with other cancers.This retrospective cohort study used population-level data on patients aged 18 years or older with cancer who participated in the 2019 National Health Interview Survey and had completed the Personal Health Questionnaire-8 (PHQ-8). The analysis was performed between August 7, 2023, and April 5, 2024.Any cancer diagnosis.The main outcome was prevalence and severity of depression based on the PHQ-8. The magnitude of the difference in baseline characteristics was measured between patients with HNC and those with other cancer types, and 95% CIs were used to measure the precision of these estimates. Multivariable logistic regressions were used to evaluate the association of demographic, socioeconomic, anxiety, and clinical variables with depression.From a weighted cohort of 23 496 725 adult patients with cancer, 377 080 were diagnosed with HNC (87.5% aged 51-84 years; 77.9% male). The prevalence of any depression on the PHQ-8 (mild, moderate, or severe) was 40.1% in patients with HNC vs 22.3% in patients with other cancers. Compared with patients with other cancers, patients with HNC were equally likely to screen positive for anxiety (23.6% vs 16.0%; difference, 7.6%; 95% CI, -5.9% to 21.1%), take medication for depression (10.1% vs 13.9%; difference, -3.8%; 95% CI, -11.9% to 4.4%), and state that they never feel depressed (59.7% vs 53.7%; difference, 6.0%; 95% CI, -9.1% to 21.0%). On multivariable logistic regression analysis, having HNC was associated with an increased likelihood of depression (odds ratio [OR], 2.94; 95% CI, 1.39-6.22). Other factors associated with depression were being unmarried or not living with a partner (OR, 1.94; 95% CI, 1.55-2.43) and having anxiety (OR, 23.14; 95% CI, 17.62-30.37).This cohort study found that patients with HNC were twice as likely to screen positive for depression on a validated survey than those with other cancers, despite having similar rates of self-reported depression and depression medication use. These findings suggest that self-reporting of depression may result in underreporting and undertreatment in this population and, thus, a need for further work in developing interventions to improve identification of and optimize treatment for patients with HNC and comorbid depression.

  View details for DOI 10.1001/jamaoto.2024.3233

  View details for PubMedID 39446380

• Feasibility of a Novel 3D Ultrasound Imaging Technique for Intraoperative Margin Assessment during Tongue Cancer Surgery. Current oncology (Toronto, Ont.) Makouei, F., Frehr, T. D., Agander, T. K., Lelkaitis, G., Hyldig Dal, M., Kaltoft, M., Orloff, L., Sebelik, M., Søndergaard Svendsen, M. B., Wessel, I., Todsen, T. 2024; 31 (8): 4414-4431

  Abstract

  Squamous cell carcinoma (SCC) of the tongue is the most prevalent form of oral cavity cancer, with surgical intervention as the preferred method of treatment. Achieving negative or free resection margins of at least 5 mm is associated with improved local control and prolonged survival. Nonetheless, margins that are close (1-5 mm) or positive (less than 1 mm) are often observed in practice, especially for the deep margins. Ultrasound is a promising tool for assessing the depth of invasion, providing non-invasive, real-time imaging for accurate evaluation. We conducted a clinical trial using a novel portable 3D ultrasound imaging technique to assess ex vivo surgical margin assessment in the operating room. During the operation, resected surgical specimens underwent 3D ultrasound scanning. Four head and neck surgeons measured the surgical margins (deep, medial, and lateral) and tumor area on the 3D ultrasound volume. These results were then compared with the histopathology findings evaluated by two head and neck pathologists. Six patients diagnosed with tongue SCC (three T1 stage and three T2 stage) were enrolled for a consecutive cohort. The margin status was correctly categorized as free by 3D ultrasound in five cases, and one case with a "free" margin status was incorrectly categorized by 3D ultrasound as a "close" margin. The Pearson correlation between ultrasound and histopathology was 0.7 (p < 0.001), 0.6 (p < 0.001), and 0.3 (p < 0.05) for deep, medial, and lateral margin measurements, respectively. Bland-Altman analysis compared the mean difference and 95% limits of agreement (LOA) for deep margin measurement by 3D ultrasound and histopathology, with a mean difference of 0.7 mm (SD 1.15 mm). This clinical trial found that 3D ultrasound is accurate in deep margin measurements. The implementation of intraoperative 3D ultrasound imaging of surgical specimens may improve the number of free margins after tongue cancer treatment.

  View details for DOI 10.3390/curroncol31080330

  View details for PubMedID 39195313

• Parathyroid Adenoma Orientation for Gland Embryologic Origin on Ultrasonography. JAMA otolaryngology-- head & neck surgery Hannabass, K. R., Austerlitz, J., Noel, J. E., Orloff, L. A. 2024

  Abstract

  Importance: Accurate preoperative localization is critical to success in targeted parathyroidectomy for primary hyperparathyroidism.Objective: To determine if the association between the long axis of a parathyroid adenoma (PTA) candidate and strap musculature on sagittal ultrasonography (US) can be used to predict the embryologic origin of the gland.Design, Setting, and Participants: This diagnostic study was performed using the Stanford Research Repository. Patients 18 years or older with primary hyperparathyroidism who underwent parathyroidectomy between January 2009 and October 2021 were considered. Additional inclusion criteria were having clear sagittal view of the adenoma candidate on US, confirmation of the gland of origin intraoperatively, and confirmation of hypercellular parathyroid on final pathology. Data were analyzed from October 2021 to June 2022.Exposures: B-mode US and surgical parathyroidectomy.Main Outcomes and Measures: The index test was using US to measure the angle between the long axis of an adenoma candidate and the strap musculature in the sagittal plane. This angle was used to test whether inferior and superior PTAs could be accurately assigned. The hypothesis was formulated prior to data collection.Results: A total of 426 patients (mean [range] age, 61.1 [20-96] years; 316 [74.2%] female) with 442 adenomas met inclusion criteria. Of the 442 adenomas, 314 (71.0%) had measurable angles, of which 204 (46.2%) were assigned a superior origin, 238 (53.8%) were assigned an inferior origin, and 128 (29%) were indeterminate. Of the surgically identified superior PTAs, 144 (70.6%) had a definable angle, and of the surgically identified inferior PTAs, 170 (71.4%) had a definable angle. The receiver operating characteristic analysis found 94° as the optimized angle for differentiating true negatives from true positives, with an overall sensitivity of 74% and specificity of 72%. This supported using 90° as a break point for US review. True positives were considered superior adenomas with an angle greater than 90°; true negatives were inferior adenomas with an angle less than 90°. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of angulation analysis for determining PTA origin were 72.2% (95% CI, 64.9%-79.5%), 73.5% (95% CI, 66.9%-80.1%), 69.8% (95% CI, 62.5%-77.1%), 75.8% (95% CI, 69.3%-82.3%), and 72.9%, respectively. A subgroup analysis of 426 adenomas using the posterior carotid artery border on transverse US as a surrogate for predicting gland origin showed the following for sensitivity, specificity, positive predictive value, negative predictive value, and accuracy: 49.5% (95% CI, 42.6%-56.4%), 82.3% (95% CI, 77.3%-87.3%), 71.4% (95% CI, 63.9%-78.9%), 64.6% (95% CI, 59.1%-70.1%), and 66.9%, respectively.Conclusions and Relevance: This diagnostic study showed that PTA angulation on sagittal plane US can be used to predict gland of origin and guide surgery. The relationship between adenoma and posterior carotid artery border on transverse US can also be used to predict gland origin. These easy-to-apply US-based tests can be used in conjunction with other imaging modalities to guide targeted parathyroidectomy.

  View details for DOI 10.1001/jamaoto.2024.1571

  View details for PubMedID 39023906

• Thyroid Nodule Rupture Following Radiofrequency Ablation for Benign Thyroid Nodules. JAMA otolaryngology-- head & neck surgery Austerlitz, J., Mann, D. S., Noel, J. E., Orloff, L. A. 2024

  Abstract

  Nodule rupture is a rare but serious complication of thyroid radiofrequency ablation (RFA). With growing adoption of thyroid RFA across the US, an understanding of thyroid nodule rupture (TNR) is crucial for recognition, management, and, ultimately, prevention.To determine procedural and patient factors that may contribute to TNR and describe experiences in managing TNR while synthesizing existing literature.This retrospective case series examined all RFA procedures for benign thyroid nodules performed by 2 attending physicians at a single academic referral center between December 2019 and January 2024. A total of 298 consecutive patients underwent RFA for benign thyroid nodules. Criteria for offering RFA included nodules with 2 benign fine-needle aspirations, no suspicious ultrasonography features, a greatest dimension of 2 cm or greater, compressive or cosmetic concerns, and accessibility to a straight needle.All RFAs were performed using ultrasonography guidance using the moving-shot technique and a 7-mm or 10-mm active tip.The primary outcome was TNR, and measures were procedure, nodule, and patient characteristics that may have contributed to its pathogenesis. Secondary outcomes were nodule volume reduction, thyroid function, and management and sequelae of TNR. The hypothesis on the pathogenesis of TNR was formed before data collection.Six of 298 patients (2%; 4 women [67%]) with a mean age of 48.5 years (range, 34-65 years) experienced TNR for a mean of 36 days postprocedure (range, 19-54 days). The mean (SD) initial nodule volume among patients with TNR was 31.45 (16.52) mL, and 3 of 6 patients (50%) underwent prior lobectomy. All ruptures were anterior. All patients were treated conservatively, and none required surgery. Five patients recovered completely; the sixth and most recent patient was healing as of last follow-up.There are limited data on the etiology and optimal management of TNR. These 6 cases of anterior rupture suggest that a potential contributor to TNR is thermal and mechanical trauma exerted at the fulcrum point during the moving-shot technique. The use of a smaller active tip (eg, 7 mm) and cessation of energy delivery before this point may help avoid TNR. More robust reporting of this complication may clarify risk factors for and enhance prevention of TNR.

  View details for DOI 10.1001/jamaoto.2024.1400

  View details for PubMedID 38869909

• Proposal for standardized ultrasound analysis of the salivary glands: Part 1 submandibular gland. Laryngoscope investigative otolaryngology Hoffman, H. T., Koch, M., Witt, R. L., Ryan, W. R., Zenk, J., Katz, P., Rahmati, R., Rassekh, C., Donato, F., McCulloch, T. M., Joshi, A. S., Chang, J. L., Gillespie, M. B., Pichardo, P. F., Orloff, L. A., Marcelino, A., Wenzel, P., Cohen, D., Fundakowski, C. E., Cognetti, D. M., Walvekar, R. R., Bertelli, A., Quon, H., Anderson, C., Policeni, B., Siegel, G. 2024; 9 (1): e1224

  Abstract

  The Salivary Gland Committee of the American Academy of Otolaryngology-Head and Neck Surgery seeks to standardize terminology and technique for ultrasonograpy used in the evaluation and treatment of salivary gland disorders.Development of expert opinion obtained through interaction with international practitioners representing multiple specialties. This committee work includes a comprehensive literature review with presentation of case examples to propose a standardized protocol for the language used in ultrasound salivary gland assessment.A multiple segment proposal is initiated with this focus on the submandibular gland. We provide a concise rationale for recommended descriptive language highlighted by a more extensive supplement that includes an extensive literature review with additional case examples.Recommendations are provided to improve consistency both in performing and reporting submandibular gland ultrasound.

  View details for DOI 10.1002/lio2.1224

  View details for PubMedID 38362174

  View details for PubMedCentralID PMC10866606

• Radiofrequency ablation of benign thyroid nodules: A prospective, multi-institutional North American experience. Surgery Russell, J. O., Desai, D. D., Noel, J. E., Hussein, M., Toraih, E., Seo, S., Wolfe, S., Omar, M., Issa, P., Orloff, L. A., Tufano, R. P., Kandil, E. 2023

  Abstract

  Radiofrequency ablation for benign thyroid nodules aims to achieve a volume reduction rate of ≥50%. However, factors that predict treatment success have not been defined in a large-scale study.A prospective cohort study of biopsy-proven benign thyroid nodules treated with radiofrequency ablation at 3 institutions was performed. Patient demographics, nodule sonographic features, procedural data, and nodule volume reduction were evaluated. Binary logistic regression analysis was performed to identify features associated with treatment response.A total of 620 nodules were analyzed. The pooled median volume reduction rate at 12 months was 70.9% (interquartile range 52.9-86.6). At 1 year follow-up, 78.4% of nodules reached treatment success with a volume reduction rate ≥50%. The overall complication rate was 3.2% and included temporary voice changes (n = 14), vasovagal episodes (n = 5), nodule rupture (n = 3), and lightheadedness (n = 2). No permanent voice changes occurred. Four patients developed postprocedural hypothyroidism. Large baseline nodule volume (>20 mL) was associated with a lower rate of successful volume reduction (odds ratio 0.60 [0.37-0.976]). Large nodules achieved treatment success by 12-month follow-up at a rate of 64.5%, compared with 81.4% for small nodules and 87.2% for medium nodules.To our knowledge, this is the largest North American cohort of patients with benign thyroid nodules treated with radiofrequency ablation. Overall, radiofrequency ablation was an effective treatment option with a low risk of procedural complications. Large volume nodules (>20 mL) may be associated with a lower rate of successful reduction with radiofrequency ablation treatment.

  View details for DOI 10.1016/j.surg.2023.07.046

  View details for PubMedID 37953141

• International Expert Consensus on US Lexicon for Thyroid Nodules. Radiology Durante, C., Hegedüs, L., Na, D. G., Papini, E., Sipos, J. A., Baek, J. H., Frasoldati, A., Grani, G., Grant, E., Horvath, E., Hoang, J. K., Mandel, S. J., Middleton, W. D., Ngu, R., Orloff, L. A., Shin, J. H., Trimboli, P., Yoon, J. H., Tessler, F. N. 2023; 309 (1): e231481

  Abstract

  Multiple US-based systems for risk stratification of thyroid nodules are in use worldwide. Unfortunately, the malignancy probability assigned to a nodule varies, and terms and definitions are not consistent, leading to confusion and making it challenging to compare study results and craft revisions. Consistent application of these systems is further hampered by interobserver variability in identifying the sonographic features on which they are founded. In 2018, an international multidisciplinary group of 19 physicians with expertise in thyroid sonography (termed the International Thyroid Nodule Ultrasound Working Group) was convened with the goal of developing an international system, tentatively called the International Thyroid Imaging Reporting and Data System, or I-TIRADS, in two phases: (phase I) creation of a lexicon and atlas of US descriptors of thyroid nodules and (phase II) development of a system that estimates the malignancy risk of a thyroid nodule. This article presents the methods and results of phase I. The purpose herein is to show what has been accomplished thus far, as well as generate interest in and support for this effort in the global thyroid community.

  View details for DOI 10.1148/radiol.231481

  View details for PubMedID 37906014

• Pearls of Parathyroidectomy: How to Find the Hard to Find Ones. Otolaryngologic clinics of North America Fullerton, Z. H., Orloff, L. A. 2023

  Abstract

  The treatment of hyperparathyroidism through parathyroidectomy requires careful and complete preoperative evaluation. There are multiple imaging modalities and methods available to clinicians today to aid in identifying a pathological lesion; however, each has limitations that the clinician must understand. A systematic approach to patient evaluation, imaging, and surgical exploration is necessary to ensure accurate diagnosis and maximize the chances of minimally invasive and successful surgical removal.

  View details for DOI 10.1016/j.otc.2023.07.004

  View details for PubMedID 37634984

• History of Thyroid Surgery in the Last Century. Thyroid : official journal of the American Thyroid Association Orloff, L. A., Parangi, S. 2023

  Abstract

  Before the 20th century, thyroid surgery was regarded as "horrid butchery" such that no honest and sensible surgeon would ever engage in it. Yet, by the mid-20th century, thyroidectomy had become a respected, life-saving, safe, and increasingly practiced operation. From Kocher to Wells and onward into the 21st century, the evolution of thyroid surgery has continued, enhanced by the integration of endocrinology, genetics, immunology, physiology, technology, training, and multidisciplinary care. The ability to personalize and optimize the care of thyroid disorders has been progressively achieved through shared insights and discoveries, highlights of which are described herein.

  View details for DOI 10.1089/thy.2022.0629

  View details for PubMedID 37594750

• Redefining "Value" in Surgery: Development of a Comprehensive Value Score for Outpatient Endocrine Surgery. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Ayoub, N. F., Noel, J., Orloff, L. A., Balakrishnan, K. 2023

  Abstract

  The value-based healthcare model aims to improve the quality of care and lower health care costs. The standard value equation (ie, Value = Quality/Cost), while conceptually useful, is grossly oversimplified and lacks clinical relevance. This study introduces a more detailed value equation that generates disease-specific value scores and incorporates real-world clinical and cost data to demonstrate its use.Prospective observational study.Tertiary institution.A comprehensive new health care value equation was developed that includes 23 unique inputs. Sixteen inputs represent quality (numerator) and 7 inputs represent cost (denominator). Patients undergoing thyroid or parathyroid surgery were enrolled, and data were entered into the new equation to generate surgery-specific value scores for each patient. A subanalysis was performed for telehealth visits.Ten patients were enrolled (60% female) with an average age of 62 years. The average total monetary cost per patient was $41,884 ($27,885 direct). Across all patients, the average total quality score was 0.99, and the cost score was 6.1, resulting in a final value score of 0.19. A subanalysis showed that changing a postoperative visit from in-person to telehealth would increase the value score by 0.66%.This analysis creates a comprehensive value equation for surgical services that incorporates the complexity of modern surgical care. The new equation includes objective and subjective outcomes and health equity, quantitatively compares the value of different surgical interventions and health care services, illustrates how specific interventions can lead to the higher value of care, and can serve as the framework for future value equations.

  View details for DOI 10.1002/ohn.427

  View details for PubMedID 37435656

• Opioid-Sparing Protocol for Endocrine Surgery (OSPREY): A Prospective Study. Journal of the American College of Surgeons Kligerman, M. P., Austerlitz, J., Orloff, L. A., Noel, J. E. 2023

  Abstract

  BACKGROUND: Thyroid and parathyroid operations are amongst the most commonly performed surgeries in the world; however, there remains a paucity of prospective clinical trials evaluating the efficacy of opioid-sparing protocols following surgery.STUDY DESIGN: This prospective non-randomized study was performed between March and October 2021. Participants self-selected their cohort of either an opioid-sparing protocol of acetaminophen/ibuprofen or a treatment-as-usual protocol with opioids. Primary endpoints were Overall Benefit of Analgesia Scores (OBAS) and opioid use as reported in daily medication logs. Data were recorded over seven days. Multivariable regression, pooled variance t-tests, Mann-Whitney test, and chi-square tests were used to evaluate the results.RESULTS: A total of 87 participants were recruited; 48 participants opted for the opioid-sparing arm while 39 participants opted for the treatment as usual arm. Patients in the opioid-sparing arm used significantly less opioids (morphine equivalents 0.77±1.71 vs. 3.34±5.87, p=0.042) but had no significant difference in OBAS (p=0.37). Multivariable regression analysis demonstrated no significant difference in mean OBAS between treatment arms when controlling for age, sex, and type of surgery (p=0.88). There were no major adverse events in either group.CONCLUSIONS: An opioid-sparing treatment algorithm based on use of acetaminophen/ibuprofen may offer a safe and effective treatment algorithm compared to a primary opioid focused treatment pathway. Randomized adequately-powered studies are needed to confirm these findings.

  View details for DOI 10.1097/XCS.0000000000000782

  View details for PubMedID 37283459

• Preoperative Evaluation of Thyroid Cancer - a review of current best practices. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists Russell, M. D., Shonka, D. C., Noel, J., Karcioglu, A. S., Ahmed, A. H., Angelos, P., Atkins, K., Bischoff, L., Buczek, E., Caulley, L., Freeman, J., Kroeker, T., Liddy, W., McIver, B., McMullen, C., Nikiforov, Y., Orloff, L., Scharpf, J., Shah, J., Shaha, A., Singer, M., Tolley, N., Tuttle, R. M., Witterick, I., Randolph, G. W. 2023

  Abstract

  OBJECTIVE: Thyroid cancer incidence has increased significantly in recent decades. While most thyroid cancers are small and carry an excellent prognosis, a subset of patients present with advanced thyroid cancer which is associated with increased rates of morbidity and mortality. Management of thyroid cancer requires a thoughtful individualized approach in order to optimize oncologic outcomes and minimize morbidity associated with treatment. Since endocrinologists usually play a key role in the initial diagnosis and evaluation of thyroid cancers, a thorough understanding of the critical components of the preoperative evaluation facilitates the development of a timely and comprehensive management plan. The following review outlines considerations in the preoperative evaluation of patients with thyroid cancer.METHODS: A clinical review based on current literature was generated by a multidisciplinary author panel.RESULTS: A review of considerations in the preoperative evaluation of thyroid cancer is provided. Topic areas include initial clinical evaluation, imaging modalities, cytologic evaluation, and the evolving role of mutational testing. Special considerations in the management of advanced thyroid cancer are discussed.CONCLUSIONS: Thorough and thoughtful preoperative evaluation is critical to formulating an appropriate treatment strategy in the management of thyroid cancer.

  View details for DOI 10.1016/j.eprac.2023.05.009

  View details for PubMedID 37236353

• Time-Driven Activity-Based Cost Comparison of Thyroid Lobectomy and Radiofrequency Ablation. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Ayoub, N. F., Balakrishnan, K., Orloff, L. A., Noel, J. E. 2023

  Abstract

  Radiofrequency ablation (RFA) of benign thyroid nodules has gained traction for its therapeutic effectiveness, thyroid function preservation, and minimally invasive nature. While a growing body of evidence reports positive outcomes from thyroid RFA, financial comparisons between both procedures remain limited. This analysis aims to more accurately measure the direct cost of thyroid RFA in comparison to thyroid lobectomy.Bottom-up financial cost analysis.Tertiary endocrine head and neck surgery center.Time-driven activity-based costing was utilized to obtain unit-based cost estimates. The care cycles for thyroid lobectomy and RFA were defined, and process maps were developed comprising all personnel and work in the care cycle. Time estimates were calculated for all personnel involved, and public government data were used to obtain capacity cost rates for each component of the care cycle. Consumable supply and overhead costs were obtained for both procedures, and overall costs were compared.For thyroid lobectomy, total personnel costs were $1087.97, consumable supplies were $942.68, and overhead costs $17,199.10. For thyroid nodule RFA performed in an office setting, the total personnel cost calculated was $379.90, consumable supplies $1315.28, and overhead $7031.20. Overall, the total cost for thyroid lobectomy was $19,229.75 compared to $8726.38 for RFA.In-office thyroid nodule RFA is associated with lower direct costs than thyroid lobectomy, and overhead is the greatest cost driver for both procedures. If clinical and patient-centered outcomes are comparable, then RFA may provide higher value for appropriately selected patients.

  View details for DOI 10.1002/ohn.360

  View details for PubMedID 37157972

• Hyperthyroidism Due to Graves Disease After Radiofrequency Ablation. JCEM case reports McAninch, E. A., Desai, K., McCowen, K. C., Orloff, L. A. 2023; 1 (3): luad056

  Abstract

  Management options for benign, autonomously functioning, and malignant thyroid nodules were limited to surgery or targeting by radioactive iodine before the availability of radiofrequency ablation (RFA). Despite being a relatively new technique, RFA may be favored for patients of high surgical risk, and for those who wish to avoid hypothyroidism. Although insurance coverage for the procedure can be a significant barrier, several groups of investigators have shown improved quality of life for RFA compared to surgery, due to the less invasive nature and favorable risk profile. Hyperthyroidism due to transient thyroiditis is a known risk of RFA, secondary to direct trauma and subsequent thyroid hormone release. Here we present a case of an adult with large, symptomatic, multinodular goiter, with no prior history of thyroid autoimmunity, who underwent RFA with successful volume reduction of two nodules, but who developed acute hyperthyroidism due to Graves disease eight weeks after RFA. Larger studies evaluating the risks of RFA should evaluate for incident hyperthyroidism, specifically for Graves disease/thyroid autoimmunity, as this could represent an additional risk of the procedure.

  View details for DOI 10.1210/jcemcr/luad056

  View details for PubMedID 37908568

  View details for PubMedCentralID PMC10580446

• Ultrasound Follow-up of Benign Thyroid Nodules: A Scoping Review. Thyroid : official journal of the American Thyroid Association Chou, R., Dana, T., Mayson, S. E., Cibas, E. S., Durante, C., Solorzano, C. C., Mandel, S., Orloff, L. A. 2023

  Abstract

  BACKGROUND: For cytologically benign thyroid nodules with very low to intermediate suspicion ultrasound patterns, optimal ultrasound follow-up intervals and outcomes of discontinuing follow-up are unclear.METHODS: Ovid MEDLINE, Embase, and Cochrane Central were searched through August 2022 for studies comparing different ultrasound follow-up intervals and discontinuation versus continuation of ultrasound follow-up. The population was patients with cytologically benign thyroid nodules and very low to intermediate suspicion ultrasound patterns and the primary outcome was missed thyroid cancers. Utilizing a scoping approach, we also included studies that were not restricted to very low to intermediate suspicion ultrasound patterns or evaluated additional outcomes such as thyroid cancer-related mortality, nodule growth, and subsequent procedures. Quality assessment was performed, and evidence was synthesized qualitatively.RESULTS: One retrospective cohort study (n=1,254; 1,819 nodules) compared different first follow-up ultrasound intervals for cytologically benign thyroid nodules. There was no difference between greater than 4- versus 1-2 year interval to first follow-up ultrasound in likelihood of malignancy (0.4% [1/223] vs. 0.3% [2/715]) and no cancer-related deaths occurred. Follow-up ultrasound at >4 years was associated with increased likelihood of ≥50% nodule growth (35.0% [78/223] vs. 15.1% [108/715]), repeat fine needle aspiration (19.3% [43/223] vs. 5.6% [40/715]) and thyroidectomy (4.0% [9/223] vs. 0.8% [6/715]). The study did not describe ultrasound patterns or control for confounders, and analyses were based on interval to first follow-up ultrasound only. Other methodological limitations were not controlling for variability in follow-up duration and unclear attrition. The certainty of evidence was very low. No study compared discontinuation of ultrasound follow-up versus continuation.CONCLUSIONS: This scoping review found that evidence comparing different ultrasound follow-up intervals in patients with benign thyroid nodules is limited to one observational study but suggests that subsequent development of thyroid malignancies is very uncommon regardless of follow-up interval. Longer follow-up may be associated with more repeat biopsies and thyroidectomies, which could be related to more interval nodule growth that meets thresholds for further evaluation. Research is needed to clarify optimal ultrasound follow-up intervals for low to intermediate suspicion cytologically benign thyroid nodules and outcomes of discontinuing ultrasound follow-up for very low suspicion nodules.

  View details for DOI 10.1089/thy.2022.0692

  View details for PubMedID 36800900

• Prognostication of papillary thyroid microcarcinoma based on preoperative ultrasound. Frontiers in endocrinology Cohen, S. M., Noel, J. E., Baroody, M., Orloff, L. A. 2023; 14: 1101705

  Abstract

  Diagnosis of papillary thyroid microcarcinoma, defined as papillary thyroid carcinoma measuring 1cm or less in greatest diameter, has increased with improvements in ultrasound technology and widespread familiarity and utilization. Given the indolent course of papillary thyroid carcinoma, active surveillance is considered an acceptable alternative to surgical resection for select patients. Candidacy for active surveillance is determined by a number of patient and tumor characteristics. Specifically, the location of the tumor within the thyroid gland plays one of the key roles in decision making. Here we evaluate characteristics of the primary tumor and distance to the thyroid capsule in association with locoregional metastases to help guide risk assessment.Retrospective chart review of all thyroid surgeries performed by two surgeons at one medical center from 2014-2021 to evaluate characteristics of papillary thyroid microcarcinoma on preoperative ultrasound that are associated with locoregional metastatic disease.Our data show a sensitivity of 65% and specificity of 95% for identifying regional metastases in papillary thyroid microcarcinoma using preoperative ultrasound. We found no correlation between regional metastasis and size of tumor, distance to thyroid capsule or trachea, tumor contour, or presence of autoimmune thyroiditis. Nodules in the superior or midpole were associated with central or lateral neck metastases, whereas nodules in the isthmus or inferior pole were only associated with central neck metastases.Active surveillance may be a reasonable option for even those papillary thyroid microcarcinomas adjacent to the thyroid capsule.

  View details for DOI 10.3389/fendo.2023.1101705

  View details for PubMedID 36793279

  View details for PubMedCentralID PMC9922900

• Parathyroid Autofluorescence in Pediatric Thyroid Surgery: Experience With False Positive and False Negative Results OTOLARYNGOLOGY-HEAD AND NECK SURGERY Su-Velez, B. M., Hartman, G. E., Seeley, H., Orloff, L. A., Noel, J. E., Meister, K. D. 2023

  View details for DOI 10.1002/ohn.272

  View details for Web of Science ID 000921354900001

• Parathyroid Autofluorescence in Pediatric Thyroid Surgery: Experience With False Positive and False Negative Results. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Su-Velez, B. M., Hartman, G. E., Seeley, H., Orloff, L. A., Noel, J. E., Meister, K. D. 2023

  Abstract

  Devices for near-infrared light stimulation of autofluorescence (NIRAF) allow for intraoperative identification of parathyroid glands with high sensitivity in adults. However, their performance in the pediatric population is unknown. In this case series with chart review at a tertiary academic children's hospital, we investigated pediatric patients undergoing thyroid surgery and concurrent use of a probe-based NIRAF device. Thirteen patients (ages 6-18 years) underwent thyroid and/or neck dissection procedures, and 2 patients had revision procedures for a total of 15 cases with the NIRAF device. Eight cases had NIRAF values that matched surgeon opinion of parathyroid tissue or histology when available. Six cases had false positive NIRAF readings (40.0%) and 1 case had false negative readings (6.7%). Compared with surgeon opinion or histology, the NIRAF device confirmed 26 of 34 parathyroid gland candidates (76.5%). These devices need further investigation in pediatric patients, whose tissues may have different autofluorescence characteristics.

  View details for DOI 10.1002/ohn.272

  View details for PubMedID 36939554

• Sociodemographic Disparities in the Diagnostic Management of Pediatric Thyroid Nodules. JAMA otolaryngology-- head & neck surgery Moon, P. K., Qian, Z. J., Noel, J. E., Orloff, L. A., Seeley, H., Hartman, G. E., Josephs, S., Meister, K. D. 2022

  Abstract

  Importance: Thyroid cancer is the most common pediatric endocrine malignant neoplasm. Disparities in the workup of thyroid nodules may be significantly associated with thyroid cancer outcomes.Objective: To determine the association of sociodemographic factors with the odds of receiving a biopsy, timeliness of the procedure, and risk of nodule malignancy.Design, Setting, and Participants: This was a retrospective cross-sectional study using insurance claims data from the Optum Clinformatics Data Mart database. The study cohort comprised pediatric patients diagnosed with single thyroid nodules between 2003 and 2020. Data analysis was performed from January 1, 2003, to June 30, 2020.Main Outcomes and Measures: Multivariable logistic regression models were used to identify demographic variables associated with biopsy and nodule malignant neoplasm. A multivariable linear regression model was used to assess the time between thyroid nodule diagnosis and biopsy.Results: Of 11 643 children (median [IQR] age at diagnosis or procedure, 15 [12-17] years; 8549 [73.2%] were female and 3126 [26.8%] were male) diagnosed with single thyroid nodules, 2117 (18.2%) received a biopsy. Among the patients who received a biopsy, 304 (14.4%) were found to have a malignant nodule. Greater parental education was associated with a shorter diagnosis-to-biopsy interval (mean difference, -7.24 days; 95% CI, -13.75 to -0.73). Older age at nodule diagnosis (odds ratio [OR], 1.11; 95% CI, 1.09-1.13) and female gender (OR, 1.25; 95% CI, 1.11-1.40) were associated with increased odds of receiving a biopsy, while Black/African American (OR, 0.80; 95% CI, 0.65-0.99) and Hispanic (OR, 0.84; 95% CI, 0.72-0.99) patients had lower odds of receiving a biopsy compared with White patients. Finally, female gender (OR, 1.08; 95% CI, 0.80-1.47) was not associated with lower odds of nodule malignant neoplasm.Conclusions and Relevance: Findings of this cross-sectional study highlight disparities in the diagnostic management of pediatric thyroid nodules. These results call for future work to ensure equitable access to thyroid care for all children.

  View details for DOI 10.1001/jamaoto.2022.3167

  View details for PubMedID 36227590

• Sonographie der Schilddruse, der Nebenschilddrusen und daruber hinaus. HNO Russell, M. D., Orloff, L. A. 2022

  Abstract

  BACKGROUND: Ultrasonography has become an essential tool for the evaluation and management of thyroid and parathyroid diseases. Its applications extend beyond neck endocrine conditions to amultitude of pathologies within the head and neck region.OBJECTIVES: Our study aimed to: (1)provide abroad review of neck ultrasonography and key findings in neck endocrine diseases; (2)support skilled performance office-based diagnostic ultrasonography and its varied applications.MATERIALS AND METHODS: A review of the current literature was supplemented with clinical examples of key ultrasonographic findings.RESULTS: Current applications and key findings of ultrasonography in the diagnosis and management of neck endocrine conditions are reviewed.CONCLUSION: Ultrasonography is afundamental component in the evaluation and management of neck endocrine diseases. The reader is encouraged to use this review to enhance office-based performance and application of ultrasonography.

  View details for DOI 10.1007/s00106-022-01162-0

  View details for PubMedID 35364686

• Radiofrequency ablation and related ultrasound-guided ablation technologies for treatment of benign and malignant thyroid disease: An international multidisciplinary consensus statement of the American Head and Neck Society Endocrine Surgery Section with the Asia Pacific Society of Thyroid Surgery, Associazione Medici Endocrinologi, British Association of Endocrine and Thyroid Surgeons, European Thyroid Association, Italian Society of Endocrine Surgery Units, Korean Society of Thyroid Radiology, Latin American Thyroid Society, and Thyroid Nodules Therapies Association. Head & neck Orloff, L. A., Noel, J. E., Stack, B. C., Russell, M. D., Angelos, P., Baek, J. H., Brumund, K. T., Chiang, F., Cunnane, M. B., Davies, L., Frasoldati, A., Feng, A. Y., Hegedus, L., Iwata, A. J., Kandil, E., Kuo, J., Lombardi, C., Lupo, M., Maia, A. L., McIver, B., Na, D. G., Novizio, R., Papini, E., Patel, K. N., Rangel, L., Russell, J. O., Shin, J., Shindo, M., Shonka, D. C., Karcioglu, A. S., Sinclair, C., Singer, M., Spiezia, S., Steck, J. H., Steward, D., Tae, K., Tolley, N., Valcavi, R., Tufano, R. P., Tuttle, R. M., Volpi, E., Wu, C. W., Abdelhamid Ahmed, A. H., Randolph, G. W. 1800

  Abstract

  BACKGROUND: The use of ultrasound-guided ablation procedures to treat both benign and malignant thyroid conditions is gaining increasing interest. This document has been developed as an international interdisciplinary evidence-based statement with a primary focus on radiofrequency ablation and is intended to serve as a manual for best practice application of ablation technologies.METHODS: A comprehensive literature review was conducted to guide statement development and generation of best practice recommendations. Modified Delphi method was applied to assess whether statements met consensus among the entire author panel.RESULTS: A review of the current state of ultrasound-guided ablation procedures for the treatment of benign and malignant thyroid conditions is presented. Eighteen best practice recommendations in topic areas of preprocedural evaluation, technique, postprocedural management, efficacy, potential complications, and implementation are provided.CONCLUSIONS: As ultrasound-guided ablation procedures are increasingly utilized in benign and malignant thyroid disease, evidence-based and thoughtful application of best practices is warranted.

  View details for DOI 10.1002/hed.26960

  View details for PubMedID 34939714

• Chromatin accessibility associates with protein-RNA correlation in human cancer. Nature communications Sanghi, A., Gruber, J. J., Metwally, A., Jiang, L., Reynolds, W., Sunwoo, J., Orloff, L., Chang, H. Y., Kasowski, M., Snyder, M. P. 2021; 12 (1): 5732

  Abstract

  Although alterations in chromatin structure are known to exist in tumors, how these alterations relate to molecular phenotypes in cancer remains to be demonstrated. Multi-omics profiling of human tumors can provide insight into how alterations in chromatin structure are propagated through the pathway of gene expression to result in malignant protein expression. We applied multi-omics profiling of chromatin accessibility, RNA abundance, and protein abundance to 36 human thyroid cancer primary tumors, metastases, and patient-match normal tissue. Through quantification of chromatin accessibility associated with active transcription units and global protein expression, we identify a local chromatin structure that is highly correlated with coordinated RNA and protein expression. In particular, we identify enhancers located within gene-bodies as predictive of correlated RNA and protein expression, that is independent of overall transcriptional activity. To demonstrate the generalizability of these findings we also identify similar results in an independent cohort of human breast cancers. Taken together, these analyses suggest that local enhancers, rather than distal enhancers, are likely most predictive of cancer gene expression phenotypes. This allows for identification of potential targets for cancer therapeutic approaches and reinforces the utility of multi-omics profiling as a methodology to understand human disease.

  View details for DOI 10.1038/s41467-021-25872-1

  View details for PubMedID 34593797

• Clinical presentation and survival outcomes of well-differentiated thyroid cancer in Filipinos. Cancer medicine Megwalu, U. C., Ma, Y., Osazuwa-Peters, N., Orloff, L. A. 2021

  Abstract

  BACKGROUND: Filipinos have higher recurrence rates compared to other racial/ethnic groups, which might suggest a higher propensity for aggressive disease. The goal of this study was to perform a population-based analysis of disease extent at diagnosis and survival outcomes in Filipino patients with well-differentiated thyroid cancer relative to other racial/ethnic groups.METHODS: The study cohort comprised adult patients with well-differentiated thyroid cancer diagnosed between 2004 and 2015, identified in the California Cancer Registry. Rates of extrathyroidal extension, nodal metastasis, and distant metastasis were compared between Filipinos, Non-Filipino Asians, and Non-Asians using multilevel logistic regression models. Survival outcomes were compared using Cox regression models, utilizing a sequential modeling approach.RESULTS: Filipino ethnicity was associated with extrathyroidal extension (OR 1.35, 95% CI 1.11-1.63) compared with non-Asians and non-Filipino Asians. Filipino ethnicity was also associated with nodal metastasis (OR 1.32, 95% CI 1.18-1.46), and with worse OS (Hazard Ratio [HR] 1.45, 95% CI 1.20-1.75) and DSS (HR 1.51, 95% CI 1.12-2.04). After adjusting for demographic and clinical factors, Filipino ethnicity was no longer associated with OS (HR 1.03, 95% CI 0.84-1.25) or DSS (HR 0.93, 95% CI 0.68-1.28).CONCLUSION: Filipino patients with thyroid cancer are more likely to present with locoregionally advanced disease compared with non-Filipino Asians and non-Asians. Furthermore, Filipino patients have worse survival outcomes compared with non-Filipino Asians and non-Asians. However, this appears to be driven by the higher rates of locoregionally advanced disease in Filipino patients.

  View details for DOI 10.1002/cam4.4149

  View details for PubMedID 34288520

• Using deep learning to identify the recurrent laryngeal nerve during thyroidectomy. Scientific reports Gong, J., Holsinger, F. C., Noel, J. E., Mitani, S., Jopling, J., Bedi, N., Koh, Y. W., Orloff, L. A., Cernea, C. R., Yeung, S. 2021; 11 (1): 14306

  Abstract

  Surgeons must visually distinguish soft-tissues, such as nerves, from surrounding anatomy to prevent complications and optimize patient outcomes. An accurate nerve segmentation and analysis tool could provide useful insight for surgical decision-making. Here, we present an end-to-end, automatic deep learning computer vision algorithm to segment and measure nerves. Unlike traditional medical imaging, our unconstrained setup with accessible handheld digital cameras, along with the unstructured open surgery scene, makes this task uniquely challenging. We investigate one common procedure, thyroidectomy, during which surgeons must avoid damaging the recurrent laryngeal nerve (RLN), which is responsible for human speech. We evaluate our segmentation algorithm on a diverse dataset across varied and challenging settings of operating room image capture, and show strong segmentation performance in the optimal image capture condition. This work lays the foundation for future research in real-time tissue discrimination and integration of accessible, intelligent tools into open surgery to provide actionable insights.

  View details for DOI 10.1038/s41598-021-93202-y

  View details for PubMedID 34253767

• Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement. Head & neck Ferrell, J. K., Shindo, M. L., Stack, B. C., Angelos, P., Bloom, G., Chen, A. Y., Davies, L., Irish, J. C., Kroeker, T., McCammon, S. D., Meltzer, C., Orloff, L. A., Panwar, A., Shin, J. J., Sinclair, C. F., Singer, M. C., Yang, T., Randolph, G. W. 2021

  Abstract

  BACKGROUND: This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking.METHODS: An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements.CONCLUSIONS: This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

  View details for DOI 10.1002/hed.26774

  View details for PubMedID 34080732

• Critical Review and Consensus Statement for Neural Monitoring in Otolaryngologic Head, Neck, and Endocrine Surgery. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Scharpf, J., Liu, J. C., Sinclair, C., Singer, M., Liddy, W., Orloff, L., Steward, D., Bonilla Velez, J., Randolph, G. W. 2021: 1945998211011062

  Abstract

  BACKGROUND: Enhancing patient outcomes in an array of surgical procedures in the head and neck requires the maintenance of complex regional functions through the protection of cranial nerve integrity. This review and consensus statement cover the scope of cranial nerve monitoring of all cranial nerves that are of practical importance in head, neck, and endocrine surgery except for cranial nerves VII and VIII within the temporal bone. Complete and applied understanding of neurophysiologic principles facilitates the surgeon's ability to monitor the at-risk nerve.METHODS: The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) identified the need for a consensus statement on cranial nerve monitoring. An AAO-HNS task force was created through soliciting experts on the subject. Relevant domains were identified, including residency education, neurophysiology, application, and various techniques for monitoring pertinent cranial nerves. A document was generated to incorporate and consolidate these domains. The panel used a modified Delphi method for consensus generation.RESULTS: Consensus was achieved in the domains of education needs and anesthesia considerations, as well as setup, troubleshooting, and documentation. Specific cranial nerve monitoring was evaluated and reached consensus for all cranial nerves in statement 4 with the exception of the spinal accessory nerve. Although the spinal accessory nerve's value can never be marginalized, the task force did not feel that the existing literature was as robust to support a recommendation of routine monitoring of this nerve. In contrast, there is robust supporting literature cited and consensus for routine monitoring in certain procedures, such as thyroid surgery, to optimize patient outcomes.CONCLUSIONS: The AAO-HNS Cranial Nerve Monitoring Task Force has provided a state-of-the-art review in neural monitoring in otolaryngologic head, neck, and endocrine surgery. The evidence-based review was complemented by consensus statements utilizing a modified Delphi method to prioritize key statements to enhance patient outcomes in an array of surgical procedures in the head and neck. A precise definition of what actually constitutes intraoperative nerve monitoring and its benefits have been provided.

  View details for DOI 10.1177/01945998211011062

  View details for PubMedID 34000898

• Neck Ultrasound: Anatomical Landmarks for Safe Performance of Neck RFA CURRENT OTORHINOLARYNGOLOGY REPORTS Noel, J. E., Orloff, L. A. 2021; 9 (1): 60-64

  View details for DOI 10.1007/s40136-020-00316-4

  View details for Web of Science ID 000702480600008

• Ultrasound Identification of Normal Parathyroid Glands. OTO open Cohen, S. M., Noel, J. E., Puccinelli, C. L., Orloff, L. A. 2021; 5 (4): 2473974X211052857

  Abstract

  Ultrasound has become indispensable for identification of thyroid and parathyroid pathology, but normal parathyroid glands have historically been considered too subtle to accurately detect. Inability to identify and protect parathyroid glands can result in hypoparathyroidism and hypocalcemia during thyroidectomy surgery as well as misinterpretation of central neck structures in the postoperative neck. Advances in ultrasound resolution have opened the door to novel applications for this technology. In this study, we report the first surgeon-performed ultrasound identification of normal parathyroid glands in a series of 6 patients, confirmed by parathyroid tissue aspirate or parathyroid autofluorescence. Recognition of normal parathyroid glands using ultrasound can be valuable for preventing postoperative hypoparathyroidism and in increasing the accuracy of postsurgical ultrasound surveillance.

  View details for DOI 10.1177/2473974X211052857

  View details for PubMedID 34723049

  View details for PubMedCentralID PMC8549471

• A Closer Look at "Taller-Than-Wide" Thyroid Nodules: Examining Dimension Ratio to Predict Malignancy. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Mattingly, A. S., Noel, J. E., Orloff, L. A. 2021: 1945998211051310

  Abstract

  To evaluate nodule height-to-width ratio as a continuous variable predicting likelihood of thyroid malignancy.Retrospective cohort study.All study information was collected from a single academic tertiary care hospital.Subjects included adult patients with thyroid nodules who underwent thyroid surgery between 2010 and 2020. The following variables were collected: patient demographics, nodule dimensions via ultrasound, fine-needle aspiration biopsy results, and surgical pathology results. Statistical analysis included logistic regression modeling malignancy with variables of interest. We used a receiver operating characteristic curve to assess the discriminatory value of variables.Height-to-width ratio, as a continuous variable, was associated with malignancy (with each 0.1 increase in ratio; odds ratio [OR], 1.25; 95% CI, 1.14-1.37). The same relationship was true for height-to-length ratio (OR, 1.36; 95% CI, 1.24-1.56). The area under the receiver operating characteristic curve for height-to-width ratio was 63.7%. In line with current emphasis on the transverse ultrasound view, we determined 4 different height-to-width ratio intervals: <0.8, 0.8 to <1.0, 1.0 to <1.5, and ≥1.5. Likelihood ratios of malignancy for each interval were 0.6, 1.0, 2.3, and 4.9, respectively.Our results support the association between greater height-to-width ratio and malignancy but suggest that a multilevel rather than binary variable improves prediction. The likelihood ratios at different intervals give a more nuanced view of how height-to-width ratio predicts malignancy. With continuing review of guidelines for thyroid nodule biopsy, it is important to consider these data for any point total attributed to shape.

  View details for DOI 10.1177/01945998211051310

  View details for PubMedID 34637345

• Pre-Operative Anti-Thyroid Antibodies in Differentiated Thyroid Cancer. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists Noel, J. E., Thatipamala, P., Hung, K. S., Chen, J., Shi, R. Z., Orloff, L. A. 2021

  Abstract

  To evaluate the significance of anti-thyroglobulin and anti-thyroid peroxidase antibody levels in locoregional metastatic disease in patients with well-differentiated thyroid cancer.Included patients underwent initial treatment for well-differentiated thyroid cancer at our institution between 2014 and 2018. The following variables were collected: age, sex, pre-operative thyroid stimulating hormone (TSH), thyroglobulin (Tg), anti-thyroglobulin antibody (TgAb), anti-thyroid peroxidase antibody (TPOAb); extent of surgery; T-stage; N-stage; extrathyroidal extension (ETE), extranodal extension (ENE), lymphovascular invasion (LVI), and multifocal disease. The relationships between pre-operative TPOAb, TgAb, Tg, and TSH and disease status were analyzed.405 patients were included in the study. 66.4% were female. Mean age was 52 years. Elevated TgAb was associated with the presence of lymph node metastases (LNM) in both the central and lateral neck (p<0.01), with stronger correlation with N1b compared with N1a disease (p=0.03). Presence of ETE was inversely associated with TgAb titer (p=0.03). TPOAb was associated with lower T- stage, fewer LNM, and lower likelihood of ETE (p=0.04, p=0.04, p=0.02). In multivariable analysis, TgAb≥40 IU/mL was an independently predictive factor of higher N-stage (p<0.01 for N0 v. N1 and p=0.01 for N1a v. N1b), and for ENE (p<0.01). TPOAb≥60 IU/mL was associated with lower T-stage (p=0.04 for T< 3) and absence of ETE (p=0.01).Elevated pre-operative TgAb was an independent predictor of nodal metastases and ENE, while elevated TPOAb was associated with a lower pathologic T and N stage. Pre-operative anti-thyroid antibody titers may be useful to inform disease extent and features.

  View details for DOI 10.1016/j.eprac.2021.06.014

  View details for PubMedID 34217894

• Use of Vascular Clues to Locate Ectopic Parathyroid Glands and Predict Anatomic Abnormalities. JAMA otolaryngology-- head & neck surgery Battista, R. A., Noel, J. E., Orloff, L. A. 2020

  View details for DOI 10.1001/jamaoto.2020.3749

  View details for PubMedID 33090209

• In Response to 'Routine Preoperative Laryngoscopy for Thyroid Surgery is Not Necessary Without Risk Factors'. Thyroid : official journal of the American Thyroid Association Walgama, E., Sinclair, C. F., Chen, A., Davies, L., Noel, J., Orloff, L. A., Shindo, M., Sigston, E., Stack Jr, B. C., Terris, D. J., Randolph, G. W. 2020

  Abstract

  none.

  View details for DOI 10.1089/thy.2020.0042

  View details for PubMedID 32228150

• Safety Recommendations for Evaluation and Surgery of the Head and Neck During the COVID-19 Pandemic. JAMA otolaryngology-- head & neck surgery Givi, B., Schiff, B. A., Chinn, S. B., Clayburgh, D., Iyer, N. G., Jalisi, S., Moore, M. G., Nathan, C., Orloff, L. A., O'Neill, J. P., Parker, N., Zender, C., Morris, L. G., Davies, L. 2020

  Abstract

  Importance: The rapidly expanding novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has challenged the medical community to an unprecedented degree. Physicians and health care workers are at added risk of exposure and infection during the course of patient care. Because of the rapid spread of this disease through respiratory droplets, health care workers who come in close contact with the upper aerodigestive tract during diagnostic and therapeutic procedures, such as otolaryngologists-head and neck surgeons, are particularly at risk. A set of safety recommendations was created based on a review of the literature and communications with physicians with firsthand knowledge of safety procedures during the COVID-19 pandemic.Observations: A high number of health care workers were infected during the first phase of the pandemic in the city of Wuhan, China. Subsequently, by adopting strict safety precautions, other regions were able to achieve high levels of safety for health care workers without jeopardizing the care of patients. The most common procedures related to the examination and treatment of upper aerodigestive tract diseases were reviewed. Each category was reviewed based on the potential risk imposed to health care workers. Specific recommendations were made based on the literature, when available, or consensus best practices. Specific safety recommendations were made for performing tracheostomy in patients with COVID-19.Conclusions and Relevance: Preserving a highly skilled health care workforce is a top priority for any community and health care system. Based on the experience of health care systems in Asia and Europe, by following strict safety guidelines, the risk of exposure and infection of health care workers could be greatly reduced while providing high levels of care. The provided recommendations, which may evolve over time, could be used as broad guidance for all health care workers who are involved in the care of patients with COVID-19.

  View details for DOI 10.1001/jamaoto.2020.0780

  View details for PubMedID 32232423

• Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective. American journal of speech-language pathology Zaga, C. J., Pandian, V. n., Brodsky, M. B., Wallace, S. n., Cameron, T. S., Chao, C. n., Orloff, L. A., Atkins, N. E., McGrath, B. A., Lazarus, C. L., Vogel, A. P., Brenner, M. J. 2020: 1–15

  Abstract

  Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.

  View details for DOI 10.1044/2020_AJSLP-20-00089

  View details for PubMedID 32525695

• A THYROID GENETIC CLASSIFIER CORRECTLY PREDICTS BENIGN NODULES WITH INDETERMINATE CYTOLOGY: TWO-INDEPENDENT MULTICENTER, PROSPECTIVE VALIDATION TRIALS. Thyroid : official journal of the American Thyroid Association Zafereo, M. n., McIver, B. n., Vargas, S. n., Domínguez Ruiz-Tagle, J. M., Steward, D. n., Holsinger, F. C., Kandil, E. n., Williams, M. D., Cruz, F. n., Loyola, S. n., Solar, A. n., Roa, J. C., Leon, A. n., Droppelmann, N. n., Arias, T. n., Lobos, M. n., Kong, C. S., Busaidy, N. n., Grubbs, E. G., Graham, P. H., Stewart, J. n., Tang, A. n., Wang, J. n., Orloff, L. A., Hernríquez-Henríquez, M. n., Lagos, M. n., Wohllk, N. n., Diaz, R. E., Véliz, J. n., Horvath, E. n., Tala, H. n., Pineda, P. n., Arroyo, P. n., Vasquez, F. n., Osorio, M. n., Schacter, D. n., Franco, C. n., Medina, F. n., Traipe, E. n., Marin, L. n., Miranda, G. n., Bruce, E. n., Bracamonte Nole, M. n., Mena, N. n., Gonzalez, H. n. 2020

  Abstract

   Although most thyroid nodules with indeterminate cytology are benign, in most of the world surgery remains as the most frequent diagnostic management. We have previously reported a 10-gene thyroid genetic classifier which accurately predicts benign thyroid nodules. The assay is a prototype diagnostic kit suitable for reference laboratory testing and could potentially avoid unnecessary diagnostic surgery in patients with indeterminate thyroid cytology.Classifier performance was tested in two independent, ethnically diverse, prospective, multicenter trials (TGCT-1/Chile and TGCT-2/USA). A total of 4061 fine-needle aspirations were collected from 15 institutions of which 897 (22%) were called indeterminate. The clinical site was blind to the classifier score and the clinical laboratory blind to pathology report. A matched surgical pathology and valid classifier score was available for 270 samples.Cohorts showed significant differences including; i) clinical site patient source (academic, 43% and 97% for TGCT-1 and 2, respectively), ii) ethnic diversity, with greater proportion of Hispanic (40% vs 3%) for TGCT-1 and greater proportion of African-American (11% vs 0%) and Asian (10% vs 1%) population for TGCT-2, and iii) tumor size, (mean of 1.7 cm and 2.5 cm for TGCT-1 and -2, respectively). Overall, there were no differences in the histopathological profile between cohorts. Forty-one of 155 and 45 of 115 nodules were malignant (cancer prevalence of 26% and 39% for TGCT 1 and 2, respectively). The classifier predicted 37 of 41 and 41 of 45 malignant nodules, yielding a sensitivity of 90% (95% confidence interval CI 77-97%) and 91% (95% CI 79-98%) for TGCTs 1 and 2, respectively. One hundred and one of 114 and 61 of 70 nodules were correctly predicted as benign yielding a specificity of 89% (95% CI 82-94%) and 87% (95% CI 77-94%), respectively. The negative predictive values for TGCT-1 and TGCT-2 were 96% and 94%, respectively, whereas the positive predictive values were 74% and 82%, respectively. The overall accuracy for both cohorts was 89%.Clinical validation of the classifier demonstrates equivalent performance in two independent and ethnically diverse cohorts, accurately predicting benign thyroid nodules that can undergo surveillance as an alternative to diagnostic surgery.

  View details for DOI 10.1089/thy.2019.0490

  View details for PubMedID 31910118

• African Head and Neck Society Clinical Practice guidelines for thyroid nodules and cancer in developing countries and limited resource settings. Head & neck Zafereo, M. n., Yu, J. n., Onakoya, P. A., Aswani, J. n., Baidoo, K. n., Bogale, M. n., Cairncross, L. n., Cordes, S. n., Daniel, A. n., Diom, E. n., Maurice, M. E., Mohammed, G. M., Biadgelign, M. G., Koné, F. I., Itiere, A. n., Koch, W. n., Konney, A. n., Kundiona, I. n., Macharia, C. n., Mashamba, V. n., Moore, M. G., Mugabo, R. M., Noah, P. n., Omutsani, M. n., Orloff, L. A., Otiti, J. n., Randolph, G. W., Sebelik, M. n., Todsen, T. n., Twier, K. n., Fagan, J. J. 2020

  Abstract

  International thyroid nodule and cancer management guidelines generally fail to take into account potential limitations in diagnostic and treatment resources.Thyroid cancer specialists from the African Head and Neck Society and American Head & Neck Society Endocrine Section developed guidelines for diagnosis and management of thyroid nodules and cancer in low resource settings. Recommendations were based on literature review and expert opinion, with level of evidence defined.Using the ADAPTE process, diagnostic and treatment algorithms were adapted from the National Comprehensive Cancer Network (NCCN). Low resource settings were simulated by systematically removing elements such as availability of laboratory testing, hormone replacement, imaging, and cytopathology from NCCN guidelines.Successful management of thyroid nodules and cancer in low resource settings requires adaptation of treatment methodologies. These guidelines define specific scenarios where either more or less aggressive intervention for thyroid pathology may be advisable based on limited available resources.

  View details for DOI 10.1002/hed.26094

  View details for PubMedID 32144948

• Laryngeal Evaluation during the COVID-19 Pandemic: Transcervical Laryngeal Ultrasonography. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Noel, J. E., Orloff, L. A., Sung, K. n. 2020: 194599820922984

  Abstract

  The novel coronavirus disease (COVID-19), caused by the SARS-CoV-2 virus, has quickly become a global pandemic since its initial outbreak in China in late 2019. Institutions are faced with the challenge of upholding the standard of care while maintaining safety for health care personnel and patients. Due to the common performance of aerosol-generating endoscopic procedures in the upper respiratory tract, otolaryngologists are at uniquely high risk for potential infection. When possible, alternative diagnostic and treatment strategies should be pursued. For patients suspected of having functional laryngeal abnormalities, transcervical laryngeal ultrasound provides a rapid and noninvasive evaluation of vocal fold motion to inform decisions about safety of feeding, airway, and progression of care.

  View details for DOI 10.1177/0194599820922984

  View details for PubMedID 32340541

• Quality of Life After Thyroidectomy for Hashimoto Disease in Patients With Persistent Symptoms. Ear, nose, & throat journal Thatipamala, P. n., Noel, J. E., Orloff, L. n. 2020: 145561320967332

  Abstract

  To determine whether thyroidectomy improves quality of life in patients with Hashimoto thyroiditis with persistent symptoms despite biochemical euthyroidism.A retrospective cohort study was conducted of patients undergoing thyroidectomy for Hashimoto thyroiditis at our institution between 2014 and 2018. The following variables were collected: age, race, body mass index, preoperative symptoms, preoperative thyroid peroxidase antibody titer, thyroglobulin antibody titer, thyroid-stimulating hormone, free thyroxine, specimen weight, and histologic presence of thyroiditis. Outcomes included general health score on the Short Form 36 (SF-36) Health and responses to a questionnaire addressing postoperative disease management.A total of 19 patients were included in the study, 18 of whom were female with a mean age of 48 years. The majority of patients were Caucasian. There were no significant differences between the postoperative general health scores of the patients with Hashimoto thyroiditis and scores from a healthy control population (66.9 vs 74.1; 95% CI: -16.9 to +2.5, P = .16). There were also no differences between groups within the 7 SF-36 subscores. Elevation in preoperative thyroperoxidase antibody correlated with lower reported postoperative energy levels (r = -0.63, P = .016) and emotional well-being (r = -.55, P = .041); 87.5% of respondents reported being moderately or extremely happy with their decision to proceed with surgery.Quality of life in patients with Hashimoto thyroiditis who undergo thyroidectomy is equivalent to the general population, and the majority are satisfied with surgery. Thyroidectomy is a consideration for patients with persistent symptoms despite optimization on medical therapy.

  View details for DOI 10.1177/0145561320967332

  View details for PubMedID 33090901

• Transoral thyroidectomy with a next generation flexible robotic system: A feasibility study in a cadaveric model GLAND SURGERY Chan, J. K., Koh, Y. W., Richmon, J., Kim, J., Holsinger, F., Orloff, L., Anuwong, A. 2019; 8 (6): 644-+

  View details for DOI 10.21037/gs.2019.10.13

  View details for Web of Science ID 000505067500010

• Transoral thyroidectomy with a next generation flexible robotic system: A feasibility study in a cadaveric model. Gland surgery Chan, J. Y., Koh, Y. W., Richmon, J., Kim, J., Holsinger, F. C., Orloff, L., Anuwong, A. 2019; 8 (6): 644-647

  Abstract

  Transoral endoscopic thyroidectomy provides access via the oral vestibule and gas insufflation to provide reliable remote access surgery to perform a total thyroidectomy. The da Vinci SP (Intuitive Surgical Inc., Sunnyvale, CA, USA) is a next generation flexible single port system that offers unique advantages over previous robotic rigid systems. Here we sought to evaluate the feasibility of performing transoral thyroidectomy with this next generation flexible robotic system.Cadaveric dissection with gas insufflation to test the feasibility of performing transoral thyroidectomy with the da Vinci SP.A 2 cm incision was made in the oral vestibule and the working space created with a 1cm central port and two lateral 5 mm ports. Then an extra small wound protector (Applied Medical, Rancho Santa Margarita, CA) was placed through the central incision after closure of the 5 mm ports. The robotic system was then deployed through the wound protector while insufflation was maintained at ~6 mmHg. Three instrument arms were deployed. A fenestrated bipolar was used to grasp the thyroid gland while Maryland bipolars and monopolar scissors were used to mobilize each hemi lobe of the thyroid. The recurrent laryngeal nerves were seen and preserved bilaterally. After completion of the surgery and removal of the wound protector the vestibular incision was measured to be 3 cm. Further dissection to identify the mental nerves identified each nerve to be >1 cm from the lateral extent of the central incision.In summary, it is feasible to perform a total thyroidectomy with gas insufflation utilizing this next generation flexible robotic system. Further evaluation will be needed to validate the clinical applicability of this technique.

  View details for DOI 10.21037/gs.2019.10.13

  View details for PubMedID 32042671

  View details for PubMedCentralID PMC6989906

• Recognizing Persistent Disease in Well-Differentiated Thyroid Cancer and Association with Lymph Node Yield and Ratio. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Noel, J. E., Orloff, L. A. 2019: 194599819886123

  Abstract

  OBJECTIVE: To establish the association between lymph node yield and ratio in neck dissection for well-differentiated thyroid cancer and risk for persistent postoperative disease.STUDY DESIGN: Retrospective cohort study of patients undergoing lymphadenectomy for thyroid carcinoma.SETTING: Tertiary referral center.SUBJECTS AND METHODS: Included patients underwent central and/or lateral neck dissection for papillary thyroid carcinoma at our institution between 1994 and 2015. They were divided into a persistent disease group with biochemical and structural disease (49 patients) and a disease-free group with no disease after a minimum 2 years of follow-up (175 patients). Demographic characteristics, adjuvant therapy, tumor, and lymph node features were compared.RESULTS: There were no significant differences in demographic characteristics between the groups. The mean nodal yield of patients with central and lateral neck persistence was significantly lower than that of patients remaining disease free (4.8 vs. 11.9: odds ratio [OR] 0.69; 95% CI, 0.59 to 0.8; P<.001; 14.8 vs. 31.0: OR, 0.89; 95% CI, 0.84-0.94; P<.001, respectively). Nodal ratio was higher in patients with persistence in the central and lateral neck (74.2% vs 29.4%: OR, 1.06; 95% CI, 1.04-1.08; P < .001; 54.2% vs 19.8%: OR, 1.08; 95% CI, 1.04-1.12; P < .001, respectively).CONCLUSIONS: Lower lymph node yield and higher node ratio from cervical lymph node dissections are associated with persistent disease and have potential applications in surgical adequacy.

  View details for DOI 10.1177/0194599819886123

  View details for PubMedID 31661359

• Adjuvant external beam radiotherapy for locally invasive papillary thyroid cancer HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK Megwalu, U. C., Orloff, L. A., Ma, Y. 2019; 41 (6): 1719–24

  View details for DOI 10.1002/hed.25639

  View details for Web of Science ID 000468629500024

• Adjuvant external beam radiotherapy for locally invasive papillary thyroid cancer. Head & neck Megwalu, U. C., Orloff, L. A., Ma, Y. 2019

  Abstract

  BACKGROUND: The goal of this study was to assess the impact of adjuvant external beam radiotherapy (EBRT) on survival in patients with locally invasive papillary thyroid carcinoma.METHODS: Propensity score analysis was performed on 870 patients with surgically resected T4 papillary thyroid carcinoma, identified in the Surveillance, Epidemiology, and End Results Database between 1988 and 2013.RESULTS: EBRT was associated with worse overall survival (OS) (HR 1.60, 95% CI 1.18-2.16) and disease-specific survival (DSS) (HR 1.58, 1.09-2.30). Subset analysis of patients with major extrathyroidal invasion showed that EBRT was associated with worse OS (HR 1.53, 95% CI 1.04-2.25), but not with DSS (HR 1.57, 95% CI 0.99-2.50).CONCLUSION: Adjuvant EBRT, in the initial management of locally invasive papillary thyroid cancer, was not associated with a survival benefit. Future studies are needed to determine which subset of patients may benefit from adjuvant EBRT.

  View details for PubMedID 30620424

• Enhanced interdisciplinary communication: development of an interactive thyroid nodule/cancer disease map LARYNGOSCOPE Moubayed, S. P., Machado, R., Tuttle, R., Orloff, L. A., Randolph, G., Hernandez-Prera, J. C., Griffin, M. J., Urken, M. L. 2019; 129 (1): 269–74

  Abstract

  Deficits related to inadequate clinical communication can result in incorrect diagnoses, inappropriate surgery, incorrect disease stratification, pathologic reporting, and/or interpretation. There are currently no validated or defined solutions to disease-specific communication with regard to thyroid care.We propose a solution that could ameliorate problems arising from inadequate disease-specific communications between physicians through the development of a thyroid disease-specific database, the Thyroid Care Collaborative.To improve the quality of thyroid nodule and cancer care, we have developed an imaging module for enhanced reporting of ultrasound, cytologic, surgical, and pathologic details that are obtained during the workup and treatment of a patient.The main advantages of this disease-specific, dynamic, three-dimensional, anatomic disease map are: 1) portability across institutions and disciplines, 2) disease specificity to thyroid nodule and cancer care, and 3) ability to trigger more detailed evaluation or reconciliation of any change in a patient's status regarding the nature or the extent of a patient's disease. The first and second advantages above have been identified as areas representing opportunities for quality improvement in health informatics research. Laryngoscope, 129:269-274, 2019.

  View details for PubMedID 30194697

• Radioactive iodine in differentiated thyroid cancer: a national database perspective. Endocrine-related cancer Orosco, R. n., Hussain, T. n., Noel, J. E., Chang, D. n., Dosiou, C. n., Mittra, E. n., Divi, V. n., Orloff, L. n. 2019

  Abstract

  Radioactive iodine (RAI) is a key component in the treatment of differentiated thyroid cancer. RAI has been recommended more selectively in recent years as guidelines evolve to reflect risks and utility in certain patient subsets. In this study we sought to evaluate the survival impact of radioactive iodine in specific thyroid cancer subgroups. Nationwide retrospective cohort study of patients using the National Cancer Database (NCDB) from 2004-2012 and Surveillance, Epidemiology, and End Results (SEER) database from 1992-2009 examining patients with differentiated thyroid cancer treated with or without RAI. Primary outcomes included all-cause mortality (NCDB and SEER), and cancer-specific mortality (SEER). Cox multivariate survival analyses were applied to each dataset, and in 135 patient subgroups based on clinical and non-clinical parameters. A total of 199,371 NCDB and 77,187 SEER patients were identified. RAI was associated with improved all-cause mortality (NCDB: RAI hazard ratio (HR) 0.55, P<0.001; SEER: HR 0.64, P<0.001); and cancer-specific mortality (SEER: HR 0.82, P=0.029). Iodine therapy showed varied efficacy within each subgroup. Patients with high-risk disease experienced the greatest benefit in all-cause mortality, followed by intermediate-risk, then low-risk subgroups. Regarding cancer-specific mortality, radioactive iodine therapy was protective in high-risk patients, but did not achieve statistical significance in most intermediate-risk subgroups. Low-risk T1a subgroups demonstrated an increased likelihood of cancer-specific mortality with iodine therapy. The efficacy of RAI in patients with differentiated thyroid cancer varies by disease severity. A negative cancer-specific survival association was identified in patients with T1a disease. These findings warrant further evaluation with prospective studies.

  View details for DOI 10.1530/ERC-19-0292

  View details for PubMedID 31443087

• International neuromonitoring study group guidelines 2018: Part II: Optimal recurrent laryngeal nerve management for invasive thyroid cancer-incorporation of surgical, laryngeal, and neural electrophysiologic data. The Laryngoscope Wu, C., Dionigi, G., Barczynski, M., Chiang, F., Dralle, H., Schneider, R., Al-Quaryshi, Z., Angelos, P., Brauckhoff, K., Brooks, J. A., Cernea, C. R., Chaplin, J., Chen, A. Y., Davies, L., Diercks, G. R., Duh, Q. Y., Fundakowski, C., Goretzki, P. E., Hales, N. W., Hartl, D., Kamani, D., Kandil, E., Kyriazidis, N., Liddy, W., Miyauchi, A., Orloff, L., Rastatter, J. C., Scharpf, J., Serpell, J., Shin, J. J., Sinclair, C. F., Stack, B. C., Tolley, N. S., Slycke, S. V., Snyder, S. K., Urken, M. L., Volpi, E., Witterick, I., Wong, R. J., Woodson, G., Zafereo, M., Randolph, G. W. 2018

  Abstract

  The purpose of this publication was to inform surgeons as to the modern state-of-the-art evidence-based guidelines for management of the recurrent laryngeal nerve invaded by malignancy through blending the domains of 1) surgical intraoperative information, 2) preoperative glottic function, and 3) intraoperative real-time electrophysiologic information. These guidelines generated by the International Neural Monitoring Study Group (INMSG) are envisioned to assist the clinical decision-making process involved in recurrent laryngeal nerve management during thyroid surgery by incorporating the important information domains of not only gross surgical findings but also intraoperative recurrent laryngeal nerve functional status and preoperative laryngoscopy findings. These guidelines are presented mainly through algorithmic workflow diagrams for convenience and the ease of application. These guidelines are published in conjunction with the INMSG Guidelines Part I: Staging Bilateral Thyroid Surgery With Monitoring Loss of Signal.LEVEL OF EVIDENCE: 5 Laryngoscope, 2018.

  View details for PubMedID 30291765

• International neural monitoring study group guideline 2018 part I: Staging bilateral thyroid surgery with monitoring loss of signal. The Laryngoscope Schneider, R., Randolph, G. W., Dionigi, G., Wu, C., Barczynski, M., Chiang, F., Al-Quaryshi, Z., Angelos, P., Brauckhoff, K., Cernea, C. R., Chaplin, J., Cheetham, J., Davies, L., Goretzki, P. E., Hartl, D., Kamani, D., Kandil, E., Kyriazidis, N., Liddy, W., Orloff, L., Scharpf, J., Serpell, J., Shin, J. J., Sinclair, C. F., Singer, M. C., Snyder, S. K., Tolley, N. S., Van Slycke, S., Volpi, E., Witterick, I., Wong, R. J., Woodson, G., Zafereo, M., Dralle, H. 2018

  Abstract

  This publication offers modern, state-of-the-art International Neural Monitoring Study Group (INMSG) guidelines based on a detailed review of the recent monitoring literature. The guidelines outline evidence-based definitions of adverse electrophysiologic events, especially loss of signal, and their incorporation in surgical strategy. These recommendations are designed to reduce technique variations, enhance the quality of neural monitoring, and assist surgeons in the clinical decision-making process involved in surgical management of recurrent laryngeal nerve. The guidelines are published in conjunction with the INMSG Guidelines Part II, Optimal Recurrent Laryngeal Nerve Management for Invasive Thyroid Cancer-Incorporation of Surgical, Laryngeal, and Neural Electrophysiologic Data. Laryngoscope, 2018.

  View details for PubMedID 30289983

• AHNS Series: Do you know your guidelines? AHNS Endocrine Section Consensus Statement: State-of-the-art thyroid surgical recommendations in the era of noninvasive follicular thyroid neoplasm with papillary-like nuclear features HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK Ferris, R. L., Nikiforov, Y., Terris, D., Seethala, R. R., Ridge, J., Angelos, P., Quan-Yang Duh, Wong, R., Sabra, M. M., Fagin, J. A., McIver, B., Bernet, V. J., Harrell, R., Busaidy, N., Cibas, E. S., Faquin, W. C., Sadow, P., Baloch, Z., Shindo, M., Orloff, L., Davies, L., Randolph, G. W. 2018; 40 (9): 1881–88

  Abstract

  The newly introduced pathologic diagnosis of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) will result in less bilateral thyroid surgery as well as deescalation in T4 suppressive and radioactive iodine treatment. Although, NIFTP is a nonmalignant lesion that has nuclear features of some papillary malignancies, the challenge for the surgeon is to identify a lesion as possibly NIFTP before the pathologic diagnosis. NIFTP, due to its reduction of overall rates of malignancy, will result in the initial surgical pendulum swinging toward lobectomy instead of initial total thyroidectomy. This American Head and Neck Society endocrine section consensus statement is intended to inform preoperative evaluation to attempt to identify those patients whose final pathology report may ultimately harbor NIFTP and can be offered a conservative surgical plan to assist in cost-effective, optimal management of patients with NIFTP.

  View details for PubMedID 29947030

• Current Experience of Ultrasound Training in Otolaryngology Residency Programs. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine Meister, K. D., Vila, P. M., Bonilla-Velez, J., Sebelik, M., Orloff, L. A. 2018

  Abstract

  OBJECTIVES: The applications of using ultrasound for the evaluation and management of otolaryngologic diagnoses are expanding. The purpose of this study was to evaluate the current experience of ultrasound training in otolaryngology residency programs.METHODS: All allopathic and osteopathic otolaryngology residency programs in the United States were surveyed online via an e-mailed survey link to the resident representatives of the Section for Residents and Fellows in Training of the American Academy of Otolaryngology-Head and Neck Surgery. We present a descriptive analysis of the survey results.RESULTS: A total of 110 responses were obtained from resident representatives at MD and DO otolaryngology residency programs, representing a response rate of 94.8%. Forty-four percent of residents reported that they would not feel comfortable with performing ultrasound-guided procedures after residency; 43% reported that they do not perform ultrasound procedures as a part of their residency training; and 60% of those trainees performing ultrasound procedures do not log the procedures. Twenty-three percent of residents did not have access to an ultrasound machine. Most respondents (71%) desired more exposure to diagnostic and/or interventional ultrasound training during residency.CONCLUSIONS: Although current experience is variable, there is a strong interest in increasing resident skill acquisition in ultrasound training among otolaryngology residents. Some barriers to these goals may be a lack of trained faculty members using ultrasound and insufficient recording mechanisms for residents performing ultrasound procedures.

  View details for PubMedID 30099758

• AHNS Series: Do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: Definitive multidisciplinary joint consensus guidelines of the American Head and Neck Society and the British Association of Endocrine and Thyroid Surgeons HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK Stack, B. C., Tolley, N. S., Bartel, T. B., Bilezikian, J. P., Bodenner, D., Camacho, P., Cox, J. T., Dralle, H., Jackson, J. E., Morris, J. C., Orloff, L., Palazzo, F., Ridge, J. A., Scott-Coombes, D., Steward, D. L., Terris, D. J., Thompson, G., Randolph, G. W. 2018; 40 (8): 1617–29

  Abstract

  Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present.A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946-2017), Cochrane SR (2005-2017), CT databases (1997-2017), and Web of Science (1945-2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness.Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed.Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.

  View details for PubMedID 30070413

• American Thyroid Association Statement on Postoperative Hypoparathyroidism: Diagnosis, Prevention, and Management in Adults THYROID Orloff, L. A., Wiseman, S. M., Bernet, V. J., Fahey, T. J., Shaha, A. R., Shindo, M. L., Snyder, S. K., Stack, B. C., Sunwoo, J. B., Wang, M. B., Amer Thyroid Assoc Surgical Affair 2018; 28 (7): 830–41

  View details for DOI 10.1089/thy.2017.0309

  View details for Web of Science ID 000437070300001

• American Thyroid Association Statement on Postoperative Hypoparathyroidism: Diagnosis, Prevention, and Management in Adults. Thyroid : official journal of the American Thyroid Association Orloff, L. A., Wiseman, S., Bernet, V., Fahey, T. 3., Shaha, A. R., Shindo, M., Snyder, S. K., Stack Jr, B. C., Sunwoo, J. B., Wang, M. B. 2018

  Abstract

  BACKGROUND: Hypoparathyroidism (hypoPT) is the most common complication after bilateral thyroid operations. Thyroid surgeons must employ strategies for minimizing and preventing post-thyroidectomy hypoPT. The objective of this American Thyroid Association Surgical Affairs Committee Statement is to provide an overview of its diagnosis, prevention and treatment.SUMMARY: HypoPT occurs when a low intact parathyroid hormone (PTH) level is accompanied by hypocalcemia. Risk factors for post-thyroidectomy hypoPT include bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions. Medical and surgical strategies to minimize perioperative hypoPT include optimizing vitamin D levels, preserving parathyroid blood supply, and autotransplanting ischemic parathyroid glands. Measurement of intraoperative or early postoperative intact PTH levels following thyroidectomy can help guide patient management. In general, a postoperative PTH level <15 pg/mL indicates increased risk for acute hypoPT. Effective management of mild to moderate potential or actual postoperative hypoPT can be achieved by administering either empiric/prophylactic oral calcium and vitamin D, selective oral calcium and vitamin D based on rapid postoperative PTH level(s), or serial serum calcium levels as a guide. Monitoring for rebound hypercalcemia is necessary to avoid metabolic and renal complications. For more severe hypocalcemia, inpatient management may be necessary. Permanent hypoPT has long term consequences for both objective and subjective well-being, and should be prevented whenever possible.

  View details for PubMedID 29848235

• Thyroid cancer mortality is higher in Filipinos in the United States: An analysis using national mortality records from 2003 through 2012 CANCER Nguyen, M. T., Hu, J., Hastings, K. G., Daza, E. J., Cullen, M. R., Orloff, L. A., Palaniappan, L. P. 2017; 123 (24): 4860–67

  View details for DOI 10.1002/cncr.30925

  View details for Web of Science ID 000417078600017

• Thyroid cancer mortality is higher in Filipinos in the United States: An analysis using national mortality records from 2003 through 2012. Cancer Nguyen, M. T., Hu, J., Hastings, K. G., Daza, E. J., Cullen, M. R., Orloff, L. A., Palaniappan, L. P. 2017; 123 (24): 4860-4867

  Abstract

  Well-differentiated thyroid carcinoma has a favorable prognosis, but patients with multiple recurrences have drastically lower survival. Filipinos in the United States are known to have high rates of thyroid cancer incidence and disease recurrence. To the authors' knowledge, it is unknown whether Filipinos also have higher thyroid cancer mortality rates.The authors studied thyroid cancer mortality in Filipino, non-Filipino Asian (NFA), and non-Hispanic white (NHW) adults using US death records (2003-2012) and US Census data. Age-adjusted mortality rates and proportional mortality ratios (PMRs) were calculated. Sex, nativity status, age at death, and educational attainment also were examined.The authors examined 19,940,952 deaths. The age-adjusted mortality rates due to thyroid cancer were highest in Filipinos (1.72 deaths per 100,000 population; 95% confidence interval [95% CI], 1.51-1.95) compared with NFAs (1.03 per 100,000 population; 95% CI, 0.95-1.12) and NHWs (1.17 per 100,000 population; 95% CI, 1.16-1.18). Compared with NHWs, higher proportionate mortality was observed in Filipino women (3-5 times higher) across all age groups, and among Filipino men, the PMR was 2 to 3 times higher in the subgroup aged >55 years. Filipinos who completed a higher educational level had a notably higher PMR (5.0) compared with their counterparts who had not (3.5).Negative prognostic factors for thyroid cancer traditionally include age >45 years and male sex. The results of the current study demonstrate that Filipinos die of thyroid cancer at higher rates than NFA and NHW individuals of similar ages. Highly educated Filipinos and Filipino women may be especially at risk of poor thyroid cancer outcomes. Filipino ethnicity should be factored into clinical decision making in the management of patients with thyroid cancer. Cancer 2017;123:4860-7. © 2017 American Cancer Society.

  View details for DOI 10.1002/cncr.30958

  View details for PubMedID 28881423

  View details for PubMedCentralID PMC5716919

• Indications and extent of central neck dissection for papillary thyroid cancer: An American Head and Neck Society Consensus Statement. Head & neck Agrawal, N., Evasovich, M. R., Kandil, E., Noureldine, S. I., Felger, E. A., Tufano, R. P., Kraus, D. H., Orloff, L. A., Grogan, R., Angelos, P., Stack, B. C., McIver, B., Randolph, G. W. 2017

  Abstract

  The primary purposes of this interdisciplinary consensus statement were to review the relevant indications for central neck dissection (CND) in patients with papillary thyroid cancer (PTC) and to outline the appropriate extent and relevant techniques required to accomplish a safe and effective CND.A writing group convened by the American Head and Neck Society (AHNS) Endocrine Committee was tasked with identifying the important clinical elements to consider when managing the central neck compartment in patients with PTC based on available evidence in the literature, and the group's collective experience. The position statement paper was then submitted to the full Endocrine Committee, Education Committee, and AHNS Council.This consensus statement was developed to inform the clinical decision-making process when managing the central neck compartment in patients with PTC from the AHNS. This document is intended to provide clarity through definitions as well as a basic guideline from which to manage the central neck. It is our hope that this improves the quality and reduces variation in management of the central neck, facilitates communication, and furthers research for patients with thyroid cancer.This represents, in our opinion, contemporary optimal surgical care for this patient population and is endorsed by the American Head and Neck Society. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1269-1279, 2017.

  View details for DOI 10.1002/hed.24715

  View details for PubMedID 28449244

• Successful ablation of plunging ranula by ultrasound-guided percutaneous ethanol injection. Laryngoscope Nguyen, M. T., Orloff, L. A. 2017

  Abstract

  Evidence supporting any one treatment for plunging ranula is limited. Standard treatment-complete excision of the sublingual gland and ranula-is invasive and morbid given the close operative proximity to the submandibular duct and lingual nerve. OK-432 (Picibanil; Chugai Pharmaceutical Co., Tokyo, Japan) sclerotherapy has been studied as a less invasive treatment but is inaccessible in the United States. This report illustrates the successful management of a plunging ranula using ultrasound-guided percutaneous ethanol injection. Within 2 months of the procedure, the patient had complete resolution of the plunging ranula, with no associated side effects. We propose that ultrasound-guided percutaneous ethanol injection be considered for the management of plunging ranula. Laryngoscope, 2016.

  View details for DOI 10.1002/lary.26505

  View details for PubMedID 28407263

• An improved ATAC-seq protocol reduces background and enables interrogation of frozen tissues. Nature methods Corces, M. R., Trevino, A. E., Hamilton, E. G., Greenside, P. G., Sinnott-Armstrong, N. A., Vesuna, S. n., Satpathy, A. T., Rubin, A. J., Montine, K. S., Wu, B. n., Kathiria, A. n., Cho, S. W., Mumbach, M. R., Carter, A. C., Kasowski, M. n., Orloff, L. A., Risca, V. I., Kundaje, A. n., Khavari, P. A., Montine, T. J., Greenleaf, W. J., Chang, H. Y. 2017

  Abstract

  We present Omni-ATAC, an improved ATAC-seq protocol for chromatin accessibility profiling that works across multiple applications with substantial improvement of signal-to-background ratio and information content. The Omni-ATAC protocol generates chromatin accessibility profiles from archival frozen tissue samples and 50-μm sections, revealing the activities of disease-associated DNA elements in distinct human brain structures. The Omni-ATAC protocol enables the interrogation of personal regulomes in tissue context and translational studies.

  View details for PubMedID 28846090

• Indolent thyroid cancer: knowns and unknowns. Cancers of the head & neck Hahn, L. D., Kunder, C. A., Chen, M. M., Orloff, L. A., Desser, T. S. 2017; 2: 1

  Abstract

  Thyroid cancer incidence is rapidly increasing due to increased detection and diagnosis of indolent thyroid cancer, i.e. cancer that is likely to be clinically insignificant. Clinical, radiologic, and pathologic features predicting indolent behavior of thyroid cancer are still largely unknown and unstudied. Existing clinicopathologic staging systems are useful for providing prognosis in the context of treated thyroid cancer but are not designed for and are inadequate for predicting indolent behavior. Ultrasound studies have primarily focused on discrimination between malignant and benign nodules; some studies show promising data on using sonographic features for predicting indolence but are still in their early stages. Similarly, molecular studies are being developed to better characterize thyroid cancer and improve the yield of fine needle aspiration biopsy, but definite markers of indolent thyroid cancer have yet to be identified. Nonetheless, active surveillance has been introduced as an alternative to surgery in the case of indolent thyroid microcarcinoma, and protocols for safe surveillance are in development. As increased detection of thyroid cancer is all but inevitable, increased research on predicting indolent behavior is needed to avoid an epidemic of overtreatment.

  View details for PubMedID 31093348

  View details for PubMedCentralID PMC6460732

• Improving the adoption of thyroid cancer clinical practice guidelines. Laryngoscope Likhterov, I., Tuttle, R. M., Haser, G. C., Su, H. K., Bergman, D., Alon, E. E., Bernet, V., Brett, E., Cobin, R., Dewey, E. H., Doherty, G., Dos Reis, L. L., Klopper, J., Lee, S. L., Lupo, M. A., Machac, J., Mechanick, J. I., Milas, M., Orloff, L., Randolph, G., Ross, D. S., Rowe, M. E., Smallridge, R., Terris, D., Tufano, R. P., Urken, M. L. 2016; 126 (11): 2640-2645

  Abstract

  To present an overview of the barriers to the implementation of clinical practice guidelines (CPGs) in thyroid cancer management and to introduce a computer-based clinical support system.PubMed.A review of studies on adherence to CPGs was conducted.Awareness and adoption of CPGs is low in thyroid cancer management. Barriers to implementation include unfamiliarity with the CPGs and financial concerns. Effective interventions to improve adherence are possible, especially when they are readily accessible at the point of care delivery. Computerized clinical support systems show particular promise. The authors introduce the clinical decision making modules (CDMMs) of the Thyroid Cancer Care Collaborative, a thyroid cancer-specific electronic health record. These computer-based modules can assist clinicians with implementation of these recommendations in clinical practice.Computer-based support systems can help clinicians understand and adopt the thyroid cancer CPGs. By integrating patient characteristics and guidelines at the point of care delivery, the CDMMs can improve adherence to the guidelines and help clinicians provide high-quality, evidence-based, and individualized patient care in the management of differentiated thyroid cancer. Laryngoscope, 2016.

  View details for DOI 10.1002/lary.25986

  View details for PubMedID 27074952

• The Changing Landscape of Primary, Secondary, and Tertiary Hyperparathyroidism: Highlights from the American College of Surgeons Panel, "What's New for the Surgeon Caring for Patients with Hyperparathyroidism" JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Shindo, M., Lee, J. A., Lubitz, C. C., McCoy, K. L., Orloff, L. A., Tufano, R. P., Pasieka, J. L. 2016; 222 (6): 1240-1250

  View details for DOI 10.1016/j.jamcollsurg.2016.02.024

  View details for Web of Science ID 000376514300041

  View details for PubMedID 27107975

• Preoperative Imaging for Thyroid Cancer: Beyond Ultrasonography. JAMA otolaryngology-- head & neck surgery Orloff, L. A., Randolph, G. W. 2016; 142 (6): 515-6

  View details for DOI 10.1001/jamaoto.2016.0165

  View details for PubMedID 26985777

• ACTIVE SURVEILLANCE FOR PAPILLARY THYROID MICROCARCINOMA: NEW CHALLENGES AND OPPORTUNITIES FOR THE HEALTH CARE SYSTEM ENDOCRINE PRACTICE Haser, G. C., Tuttle, R. M., Su, H. K., Alon, E. E., Bergman, D., Bernet, V., Brett, E., Cobin, R., Dewey, E. H., Doherty, G., Dos Reis, L. L., Harris, J., Klopper, J., Lee, S. L., Levine, R. A., Lepore, S. J., Likhterov, I., Lupo, M. A., Machac, J., Mechanick, J. I., Mehra, S., Milas, M., Orloff, L. A., Randolph, G., Revenson, T. A., Roberts, K. J., Ross, D. S., Rowe, M. E., Smallridge, R. C., Terris, D., Tufano, R. P., Urken, M. L. 2016; 22 (5): 602-611

  Abstract

  The dramatic increase in papillary thyroid carcinoma (PTC) is primarily a result of early diagnosis of small cancers. Active surveillance is a promising management strategy for papillary thyroid microcarcinomas (PTMCs). However, as this management strategy gains traction in the U.S., it is imperative that patients and clinicians be properly educated, patients be followed for life, and appropriate tools be identified to implement the strategy.We review previous active surveillance studies and the parameters used to identify patients who are good candidates for active surveillance. We also review some of the challenges to implementing active surveillance protocols in the U.S. and discuss how these might be addressed.Trials of active surveillance support nonsurgical management as a viable and safe management strategy. However, numerous challenges exist, including the need for adherence to protocols, education of patients and physicians, and awareness of the impact of this strategy on patient psychology and quality of life. The Thyroid Cancer Care Collaborative (TCCC) is a portable record keeping system that can manage a mobile patient population undergoing active surveillance.With proper patient selection, organization, and patient support, active surveillance has the potential to be a long-term management strategy for select patients with PTMC. In order to address the challenges and opportunities for this approach to be successfully implemented in the U.S., it will be necessary to consider psychological and quality of life, cultural differences, and the patient's clinical status.

  View details for DOI 10.4158/EP151065.RA

  View details for Web of Science ID 000377969400011

  View details for PubMedID 26799628

• Prognostic Implications of Lymph Node Yield in Central and Lateral Neck Dissections for Well-Differentiated Papillary Thyroid Carcinoma. Thyroid Heaton, C. M., Chang, J. L., Orloff, L. A. 2016; 26 (3): 434-440

  Abstract

  The aim of this study was to evaluate the relationship between lymph node yield (LNY) from central (CND) and lateral (LND) neck dissections and risk of recurrence in patients undergoing primary surgery for well-differentiated papillary thyroid carcinoma (WDPTC).Clinical data were reviewed from all patients with biopsy-proven WDPTC who underwent primary total thyroidectomy with CND or LND at the authors' institution from 2005 to 2009. Patient demographics and tumor characteristics were obtained, and clinical data with at least five-year follow-up were used. Within the CNDs and LNDs, total number of nodes removed (LNY), total positive nodes removed, and the ratio of positive lymph nodes to LNY were determined.One hundred fifty-two patients were included in the study, with average follow-up of 69 months. Of 125 patients who underwent CND, 20 had central neck disease recurrence. The LNY of patients with central neck recurrence was significantly less than those who had no recurrence (2.5 vs. 10.3; p < 0.0001). Of 71 patients who underwent LND, 23 had ipsilateral lateral neck disease recurrence. The LNY of patients with lateral neck recurrence was significantly less than those who did not recur (10.5 vs. 24.6; p < 0.0001). Higher rates of recurrence were associated with smaller LNY in both groups. For both groups, lower LNY remains predictive of recurrence on multivariate analysis controlling for pT stage, pN stage, American Joint Committee on Cancer stage, and radioactive iodine treatment.Higher LNY in CNDs and LNDs is associated with lower rates of papillary thyroid carcinoma recurrence in the central and lateral neck. To minimize the risk of recurrence and the need for secondary therapy with revision surgery and/or radiation, surgeons should perform thorough, compartment-oriented CNDs and LNDs when nodal surgery is undertaken.

  View details for DOI 10.1089/thy.2015.0318

  View details for PubMedID 26825749

• Transoral robotic-assisted surgical excision of a retropharyngeal parathyroid adenoma: A case report. Head & neck Bearelly, S., Prendes, B. L., Wang, S. J., Glastonbury, C., Orloff, L. A. 2015; 37 (11): E150-2

  Abstract

  Transoral robotic surgery has been used with increasing frequency for oropharyngeal malignancies. We present the first known case of a transoral robotic-assisted parathyroidectomy.A 77-year-old woman with primary hyperparathyroidism was suspected of having a parathyroid adenoma. After several nonlocalizing single photon emission CT/CT sestamibi scans, a neck ultrasound revealed a suspicious low level 6 nodule. Surgical excision of this nodule proved to be a reactive lymph node. She then had a dynamic parathyroid protocol MRI and CT, which revealed a small retropharyngeal adenoma candidate. A transoral robotic-assisted surgical approach was utilized to bluntly dissect the retropharyngeal space just above the arytenoids to excise the nodule. After excision, the intraoperative parathyroid hormone (PTH) normalized and surgical pathology confirmed parathyroid adenoma.Transoral robotic-assisted surgery is a novel technique that can be utilized for resection of a parathyroid adenoma in the retropharyngeal space.

  View details for DOI 10.1002/hed.24010

  View details for PubMedID 25809987

• AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY DISEASE STATE CLINICAL REVIEW: POSTOPERATIVE HYPOPARATHYRODISM - DEFINITIONS AND MANAGEMENT ENDOCRINE PRACTICE Stack, B. C., Bimston, D. N., Bodenner, D. L., Brett, E. M., Dralle, H., Orloff, L. A., Pallota, J., Snyder, S. K., Wong, R. J., Randolph, G. W. 2015; 21 (6): 674-685

  Abstract

  BID = bis in die DSPTC = diffuse sclerosing papillary thyroid cancer FNA = fine-needle aspiration HT = Hashimoto thyroiditis iPTH = intact parathyroid hormone 25OHD = 25-hydroxy vitamin D PTH = parathyroid hormone TPO = thyroid peroxidase US = ultrasonography.

  View details for DOI 10.4158/EP14462.DSC

  View details for Web of Science ID 000357732000014

  View details for PubMedID 26135962

• Stimulation Threshold Greatly Affects the Predictive Value of Intraoperative Nerve Monitoring LARYNGOSCOPE Faden, D. L., Orloff, L. A., Ayeni, T., Fink, D. S., Yung, K. 2015; 125 (5): 1265-1270

  Abstract

  Using a standardized, graded, intraoperative stimulation protocol, we aimed to delineate the effects of various stimulation levels applied to the recurrent laryngeal nerve on the postoperative predictive value of intraoperative nerve monitoring.A total of 917 nerves at risk were included for analysis. Intraoperatively, patients underwent stimulation of the recurrent laryngeal nerve at 0.3, 0.5, 0.8, and 1.0 mA followed by postoperative laryngoscopy for correlation with intraoperative findings.Sensitivity, specificity, positive predictive value, and negative predictive value were calculated at each stimulation level.Sensitivity, specificity, positive predictive value, and negative predicative values ranged from 100% to 37%, 6% to 99%, 2% to 39%, and 100% to 99%, respectively at 0.3 to 1.0 mA. No demographic variables affected sensitivity or specificity. Receiver operating characteristic analysis identified 0.5 mA as the level of stimulation that optimizes sensitivity and specificity.The predictive value of intraoperative nerve monitoring varies greatly depending on the stimulation levels used. At low amplitudes of stimulation, nerve monitoring has high sensitivity and negative predictive value but low specificity and positive predictive value, related to the high rate of false positives. At high levels of stimulation, specificity and negative predictive value are high, sensitivity is low, and the positive predictive value rises as the rate of false negatives increase and the rate of false positives decrease. A stimulation level of 0.5 mA optimizes the predictive value of nerve monitoring; however, stimulation at multiple levels significantly improves the predictive value of intraoperative nerve monitoring.2b.

  View details for DOI 10.1002/lary.24960

  View details for Web of Science ID 000353996900050

  View details for PubMedID 25302692

• Management of recurrent and persistent metastatic lymph nodes in well-differentiated thyroid cancer: a multifactorial decision-making guide for the thyroid cancer care collaborative. Head & neck Urken, M. L., Milas, M., Randolph, G. W., Tufano, R., Bergman, D., Bernet, V., Brett, E. M., Brierley, J. D., Cobin, R., Doherty, G., Klopper, J., Lee, S., Machac, J., Mechanick, J. I., Orloff, L. A., Ross, D., Smallridge, R. C., Terris, D. J., Clain, J. B., Tuttle, M. 2015; 37 (4): 605-614

  Abstract

  Well-differentiated thyroid cancer (WDTC) recurs in up to 30% of patients. Guidelines from the American Thyroid Association (ATA) and the National Comprehensive Cancer Network (NCCN) provide valuable parameters for the management of recurrent disease, but fail to guide the clinician as to the multitude of factors that should be taken into account. The Thyroid Cancer Care Collaborative (TCCC) is a web-based repository of a patient's clinical information. Ten clinical decision-making modules (CDMMs) process this information and display individualized treatment recommendations.We conducted a review of the literature and analysis of the management of patients with recurrent/persistent WDTC.Surgery remains the most common treatment in recurrent/persistent WDTC and can be performed with limited morbidity in experienced hands. However, careful observation may be the recommended course in select patients. Reoperation yields biochemical remission rates between 21% and 66%. There is a reported 1.2% incidence of permanent unexpected nerve paralysis and a 3.5% incidence of permanent hypoparathyroidism. External beam radiotherapy and percutaneous ethanol ablation have been reported as therapeutic alternatives. Radioactive iodine as a primary therapy has been reported previously for metastatic lymph nodes, but is currently advocated by the ATA as an adjuvant to surgery.The management of recurrent lymph nodes is a multifactorial decision and is best determined by a multidisciplinary team. The CDMMs allow for easy adoption of contemporary knowledge, making this information accessible to both patient and clinician.

  View details for DOI 10.1002/hed.23615

  View details for PubMedID 24436291

• Database and registry research in thyroid cancer: striving for a new and improved national thyroid cancer database. Thyroid Mehra, S., Tuttle, R. M., Milas, M., Orloff, L., Bergman, D., Bernet, V., Brett, E., Cobin, R., Doherty, G., Judson, B. L., Klopper, J., Lee, S., Lupo, M., Machac, J., Mechanick, J. I., Randolph, G., Ross, D. S., Smallridge, R., Terris, D., Tufano, R., Alon, E., Clain, J., DosReis, L., Scherl, S., Urken, M. L. 2015; 25 (2): 157-168

  Abstract

  Health registries have become extremely powerful tools for cancer research. Unfortunately, certain details and the ability to adapt to new information are necessarily limited in current registries, and they cannot address many controversial issues in cancer management. This is of particular concern in differentiated thyroid cancer, which is rapidly increasing in incidence and has many unknowns related to optimal treatment and surveillance recommendations.In this study, we review different types of health registries used in cancer research in the United States, with a focus on their advantages and disadvantages as related to the study of thyroid cancer. This analysis includes population-based cancer registries, health systems-based cancer registries, and patient-based disease registries. It is important that clinicians understand the way data are collected in, as well as the composition of, these different registries in order to more critically interpret the clinical research that is conducted using that data. In an attempt to address shortcoming of current databases for thyroid cancer, we present the potential of an innovative web-based disease management tool for thyroid cancer called the Thyroid Cancer Care Collaborative (TCCC) to become a patient-based registry that can be used to evaluate and improve the quality of care delivered to patients with thyroid cancer as well as to answer questions that we have not been able to address with current databases and registries.A cancer registry that follows a specific patient, is integrated into physician workflow, and collects data across different treatment sites and different payers does not exist in the current fragmented system of healthcare in the United States. The TCCC offers physicians who treat thyroid cancer numerous time-saving and quality improvement services, and could significantly improve patient care. With rapid adoption across the nation, the TCCC could become a new paradigm for database research in thyroid cancer to improve our understanding of thyroid cancer management.

  View details for DOI 10.1089/thy.2014.0270

  View details for PubMedID 25517683

• American Thyroid Association statement on preoperative imaging for thyroid cancer surgery. Thyroid Yeh, M. W., Bauer, A. J., Bernet, V. A., Ferris, R. L., Loevner, L. A., Mandel, S. J., Orloff, L. A., Randolph, G. W., Steward, D. L. 2015; 25 (1): 3-14

  Abstract

  The success of surgery for thyroid cancer hinges on thorough and accurate preoperative imaging, which enables complete clearance of the primary tumor and affected lymph node compartments. This working group was charged by the Surgical Affairs Committee of the American Thyroid Association to examine the available literature and to review the most appropriate imaging studies for the planning of initial and revision surgery for thyroid cancer.Ultrasound remains the most important imaging modality in the evaluation of thyroid cancer, and should be used routinely to assess both the primary tumor and all associated cervical lymph node basins preoperatively. Positive lymph nodes may be distinguished from normal nodes based upon size, shape, echogenicity, hypervascularity, loss of hilar architecture, and the presence of calcifications. Ultrasound-guided fine-needle aspiration of suspicious lymph nodes may be useful in guiding the extent of surgery. Cross-sectional imaging (computed tomography with contrast or magnetic resonance imaging) may be considered in select circumstances to better characterize tumor invasion and bulky, inferiorly located, or posteriorly located lymph nodes, or when ultrasound expertise is not available. The above recommendations are applicable to both initial and revision surgery. Functional imaging with positron emission tomography (PET) or PET-CT may be helpful in cases of recurrent cancer with positive tumor markers and negative anatomic imaging.

  View details for DOI 10.1089/thy.2014.0096

  View details for PubMedID 25188202

• Management of invasive well-differentiated thyroid cancer: An American Head and Neck Society Consensus Statement AHNS Consensus Statement HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK Shindo, M. L., Caruana, S. M., Kandil, E., McCaffrey, J. C., Orloff, L. A., Porterfield, J. R., Shaha, A., Shin, J., Terris, D., Randolph, G. 2014; 36 (10): 1379-1390

  View details for DOI 10.1002/hed.23619

  View details for Web of Science ID 000342157000004

• What Is the Gold Standard for Comprehensive Interinstitutional Communication of Perioperative Information for Thyroid Cancer Patients? A Comparison of Existing Electronic Health Records with the Current American Thyroid Association Recommendations THYROID Dos Reis, L. L., Tuttle, R. M., Alon, E., Bergman, D. A., Bernet, V., Brett, E. M., Cobin, R., Doherty, G., Harris, J. R., Klopper, J., Lee, S. L., Lupo, M., Milas, M., Machac, J., Mechanick, J. I., Orloff, L., Randolph, G., Ross, D. S., Smallridge, R. C., Terris, D. J., Tufano, R. P., Mehra, S., Scherl, S., Clain, J. B., Urken, M. L. 2014; 24 (10): 1466-1472

  Abstract

  Appropriate management of well-differentiated thyroid cancer requires treating clinicians to have access to critical elements of the patient's presentation, surgical management, postoperative course, and pathologic assessment. Electronic health records (EHRs) provide an effective method for the storage and transmission of patient information, although most commercially available EHRs are not intended to be disease-specific. In addition, there are significant challenges for the sharing of relevant clinical information when providers involved in the care of a patient with thyroid cancer are not connected by a common EHR. In 2012, the American Thyroid Association (ATA) defined the critical elements for optimal interclinician communication in a position paper entitled, "The Essential Elements of Interdisciplinary Communication of Perioperative Information for Patients Undergoing Thyroid Cancer Surgery."We present a field-by-field comparison of the ATA's essential elements as applied to three contemporary electronic reporting systems: the Thyroid Surgery e-Form from Memorial Sloan-Kettering Cancer Center (MSKCC), the Alberta WebSMR from the University of Calgary, and the Thyroid Cancer Care Collaborative (TCCC). The MSKCC e-form fulfills 21 of 32 intraoperative fields and includes an additional 14 fields not specifically mentioned in the ATA's report. The Alberta WebSMR fulfills 45 of 82 preoperative and intraoperative fields outlined by the ATA and includes 13 additional fields. The TCCC fulfills 117 of 120 fields outlined by the ATA and includes 23 additional fields.Effective management of thyroid cancer is a highly collaborative, multidisciplinary effort. The patient information that factors into clinical decisions about thyroid cancer is complex. For these reasons, EHRs are particularly favorable for the management of patients with thyroid cancer. The MSKCC Thyroid Surgery e-Form, the Alberta WebSMR, and the TCCC each meet all of the general recommendations for effective reporting of the specific domains that they cover in the management of thyroid cancer, as recommended by the ATA. However, the TCCC format is the most comprehensive. The TCCC is a new Web-based disease-specific database to enhance communication of patient information between clinicians in a Health Insurance Portability and Accountability Act (HIPAA)-compliant manner. We believe the easy-to-use TCCC format will enhance clinician communication while providing portability of thyroid cancer information for patients.

  View details for DOI 10.1089/thy.2014.0209

  View details for Web of Science ID 000342742800005

• Striving Toward Standardization of Reporting of Ultrasound Features of Thyroid Nodules and Lymph Nodes: A Multidisciplinary Consensus Statement THYROID Su, H. K., Dos Reis, L. L., Lupo, M. A., Milas, M., Orloff, L. A., Langer, J. E., Brett, E. M., Kazam, E., Lee, S. L., Minkowitz, G., Alpert, E. H., Dewey, E. H., Urken, M. L. 2014; 24 (9): 1341-1349

  Abstract

  The use of high-resolution ultrasound (US) imaging is a mainstay of the initial evaluation and long-term management of thyroid nodules and thyroid cancer. To fully capitalize on the diagnostic capabilities of a US examination in the context of thyroid disease, many clinicians consider it desirable to establish a universal format and standard of US reporting. The goals of this interdisciplinary consensus statement are twofold. First, to create a standardized set of US features to characterize thyroid nodules and cervical lymph nodes accurately, and second, to create a standardized system for tracking sequential changes in the US examination of thyroid nodules and cervical lymph nodes for the purpose of determining risk of malignancy.The Thyroid, Head and Neck Cancer (THANC) Foundation convened a panel of nine specialists from a variety of medical disciplines that are actively involved in the diagnosis and treatment of thyroid nodules and thyroid cancer. Consensus was achieved on the following topics: US evaluation of the thyroid gland, US evaluation of thyroid nodules, US evaluation of cervical lymph nodes, US-guided fine needle aspiration (FNA) of thyroid nodules, and US-guided FNA of cervical lymph nodes.We propose that this statement represents a consensus within a multidisciplinary team on the salient and essential elements of a comprehensive and clinically significant thyroid and neck US report with regards to content, terminology, and organization. This reporting protocol supplements previous US performance guidelines by not only capturing categories of findings that may have important clinical implications, but also delineating findings that are clinically relevant within those categories as specifically as possible. Additionally, we have included the specific features of diagnostic and therapeutic interventions that have not been previously addressed.

  View details for DOI 10.1089/thy.2014.0110

  View details for Web of Science ID 000341509300002

  View details for PubMedID 24967994

• Clinician-Performed Thyroid Ultrasound-Guided Fine-Needle Aspiration OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Tsao, G. J., Orloff, L. A. 2014; 47 (4): 509-?

  Abstract

  Fine needle aspiration biopsy (FNA) is the key step in selecting most patients with thyroid nodules for or against surgery. Accurate acquisition of cytologic samples from suspicious lesions is achieved by adding ultrasound guidance to optimize targeting as well as to enable sampling from nonpalpable lesions. This article discusses the indications, variations, and technical details of ultrasound-guided FNA.

  View details for DOI 10.1016/j.otc.2014.04.005

  View details for Web of Science ID 000340440800006

  View details for PubMedID 25041954

• Improving the Quality of Thyroid Cancer Care: How Does the Thyroid Cancer Care Collaborative Cross the Institute of Medicine's Quality Chasm? THYROID Mehra, S., Tuttle, R. M., Bergman, D., Bernet, V., Brett, E., Cobin, R., Doherty, G., Klopper, J., Lee, S., Machac, J., Milas, M., Mechanick, J. I., Orloff, L., Randolph, G., Ross, D. S., Smallridge, R., Terris, D., Tufano, R., Alon, E., Clain, J., Dos Reis, L., Scherl, S., Urken, M. L. 2014; 24 (4): 615-624

  Abstract

  The current systems of healthcare delivery in the United States suffer from problems that often leave patients with inadequate quality of care. In their report entitled "Crossing the Quality Chasm," the Institute of Medicine (IOM) identified reasons for poor and/or inconsistent quality of healthcare delivery and provided recommendations to improve it. The purpose of this review is to describe features of an innovative web-based program called the Thyroid Cancer Care Collaborative (TCCC) and see how it addresses IOM recommendations to improve the quality of healthcare delivery.The TCCC addresses the three actionable IOM recommendations directed at healthcare organizations and clinicians to redesign the care process. It does so by exploiting information technology (IT) in ways suggested by the IOM, and it fits within a set of 10 rules provided by the IOM. Some features of the TCCC include: (i) automated disease staging based on three validated scoring systems; (ii) highly illustrated educational videos on all aspects of thyroid cancer care; (iii) personalized clinical decision-making modules for clinicians and physicians; (iv) portability of data to share among treating physicians; (v) virtual tumor boards, "ask the expert," and frequently asked questions modules; (vi) physician workflow integration; and (vii) data for comprehensive analysis to answer difficult questions in thyroid cancer management.The TCCC has the potential to improve thyroid cancer care delivery and offers several benefits to patients, clinicians, and researchers. The TCCC is a valuable example of how IOM initiatives can improve the healthcare system.

  View details for DOI 10.1089/thy.2013.0441

  View details for Web of Science ID 000334110700001

  View details for PubMedID 24512449

• American Thyroid Association Statement on Outpatient Thyroidectomy THYROID Terris, D. J., Snyder, S., Carneiro-Pla, D., Inabnet, W. B., Kandil, E., Orloff, L., Shindo, M., Tufano, R. P., Tuttle, R. M., Urken, M., Yeh, M. W. 2013; 23 (10): 1193-1202

  Abstract

  The primary goals of this interdisciplinary consensus statement are to define the eligibility criteria for outpatient thyroidectomy and to explore preoperative, intraoperative, and postoperative factors that should be considered in order to optimize the safe and efficient performance of ambulatory surgery.A series of criteria was developed that may represent relative contraindications to outpatient thyroidectomy, and these fell into the following broad categories: clinical, social, and procedural issues. Intraoperative factors that bear consideration are enumerated, and include choice of anesthesia, use of nerve monitoring, hemostasis, management of the parathyroid glands, wound closure, and extubation. Importantly, postoperative factors are described at length, including suggested discharge criteria and recognition of complications, especially bleeding, airway distress, and hypocalcemia.Outpatient thyroidectomy may be undertaken safely in a carefully selected patient population provided that certain precautionary measures are taken to maximize communication and minimize the likelihood of complications.

  View details for DOI 10.1089/thy.2013.0049

  View details for Web of Science ID 000324832100004

  View details for PubMedID 23742254

• External branch of the superior laryngeal nerve monitoring during thyroid and parathyroid surgery: International Neural Monitoring Study Group standards guideline statement LARYNGOSCOPE Barczynski, M., Randolph, G. W., Cernea, C. R., Dralle, H., Dionigi, G., Alesina, P. F., Mihai, R., Finck, C., Lombardi, D., Hartl, D. M., Miyauchi, A., Serpell, J., Snyder, S., Volpi, E., Woodson, G., Kraimps, J. L., Hisham, A. N. 2013; 123: S1-S14

  Abstract

  Intraoperative neural monitoring (IONM) during thyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual identification of the recurrent laryngeal nerve (RLN). Contrary to routine dissection of the RLN, most surgeons tend to avoid rather than routinely expose and identify the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy or parathyroidectomy. IONM has the potential to be utilized for identification of the EBSLN and functional assessment of its integrity; therefore, IONM might contribute to voice preservation following thyroidectomy or parathyroidectomy. We reviewed the literature and the cumulative experience of the multidisciplinary International Neural Monitoring Study Group (INMSG) with IONM of the EBSLN. A systematic search of the MEDLINE database (from 1950 to the present) with predefined search terms (EBSLN, superior laryngeal nerve, stimulation, neuromonitoring, identification) was undertaken and supplemented by personal communication between members of the INMSG to identify relevant publications in the field. The hypothesis explored in this review is that the use of a standardized approach to the functional preservation of the EBSLN can be facilitated by application of IONM resulting in improved preservation of voice following thyroidectomy or parathyroidectomy. These guidelines are intended to improve the practice of neural monitoring of the EBSLN during thyroidectomy or parathyroidectomy and to optimize clinical utility of this technique based on available evidence and consensus of experts.5

  View details for DOI 10.1002/lary.24301

  View details for Web of Science ID 000323702000001

  View details for PubMedID 23832799