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Background: Newer transoral thyroidectomy techniques that aim to avoid scars in the neck and maximize cosmetic outcomes have become more prevalent. We conducted a discrete choice experiment (DCE) to evaluate the influence of cosmetic concerns and other factors on patients' decision-making processes when choosing among different thyroidectomy approaches. Methods: A questionnaire was developed to identify key attributes driving patient preferences around thyroidectomy approaches using mixed analyses of patient focus groups, expert opinion, and literature review. These attributes included (i) risk of recurrent laryngeal nerve (RLN) injury, (ii) risk of mental nerve injury, (iii) travel distance for surgery, (iv) out-of-pocket cost, and (v) incision site. Using fractional factorial design, discrete choice sets consisting of randomly generated hypothetical scenarios across all attributes were created. A face-to-face DCE survey was administered to patients being evaluated in clinic for thyroid lobectomy for noncancerous thyroid disease. Participants chose among scenarios constructed from the choice sets of attributes. Analyses were conducted using a mixed logit model, and the trade-offs between different attributes that patients were willing to accept were quantified. Results: The DCE was completed by 109 participants (86 [79%] women; mean age 51.3 ± 3.0 years). Overall, the risk of having RLN and/or mental nerve injury, travel distance, and cost were the most influential attributes. Participants aged ≤60 years significantly preferred an approach without a neck incision and were willing to accept an additional $2332 USD in out-of-pocket cost, 693 miles of travel distance, 0.6% increased risk of RLN injury, and 2.2% risk of mental nerve injury. Patients aged >60 years significantly preferred a conventional neck incision and were willing to pay an additional $3401 out-of-pocket and travel 1011 miles to avoid a scarless approach. Conclusions: The risk of nerve injury, travel distance, and cost were the most important drivers for patients choosing among surgical approaches for thyroidectomy. Cosmetic considerations also influenced patient choices, but in opposing ways depending on patient age.

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Medullary thyroid carcinoma (MTC) is a malignant tumor of the parafollicular cells, which produce calcitonin. As a result, calcitonin is an important tool for diagnosing MTC. When there is focal or no calcitonin staining, diagnosis of MTC can be challenging as this may suggest differences in cell origin and in prognosis and recurrence of the disease. The prognosis and guidelines for management and follow up for MTC remain inconclusive. Here, we present a case of primary neuroendocrine tumor of the thyroid gland with only focal calcitonin staining on immunohistochemistry and low serum calcitonin level despite a tumor size of almost 4 cm. The assumption of C-cell origin was made from positive staining for carcinoembryonic agent (CEA), thyroid transcription factor 1 (TTF-1) and paired box 8 (PAX8) without expression of thyroglobulin (Tg). The patient underwent thyroid lobectomy and follow-up monitoring with ultrasound and measurements of calcitonin and CEA levels, without any further surgical intervention. Few cases of neuroendocrine tumors with limited calcitonin expression have been published and the etiology and prognosis are still unknown. Our case suggests that limited calcitonin expression cannot completely exclude the diagnosis of MTC. This rare type of MTC should be differentiated from the typical presentation of MTC. Treatment and post-operative surveillance should be tailored based on the individual.

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BACKGROUND: The transoral endoscopic approach to thyroidectomy aims to eliminate a visible neck incision. Early experience has demonstrated promising safety and efficacy results but has uncovered unique drawbacks from the middle oral incision. We present a case series of our institutional experience with a technical innovation called the TransOral and Submental Technique (TOaST) designed to address these limitations. MATERIALS AND METHODS: We reviewed all patients who successfully underwent TOaST thyroidectomy at our institution from November 2017 to November 2018. Demographics, surgical indications, technical details, and perioperative outcomes were recorded in a prospective database and analyzed retrospectively. RESULTS: Fourteen patients underwent TOaST thyroidectomy, with mean follow-up of 17 wk. Mean age was 38 y, and all but one was female. Most cases were cytologically benign or indeterminate nodules. There were no injuries to the recurrent laryngeal or mental nerves. TOaST had no instances of chin pain or specimen disruption, two complications that have been associated with the standard transoral approach. The cosmetic outcomes remained excellent. CONCLUSIONS: This pilot study of TOaST indicates that it is a technically feasible and safe approach to thyroidectomy for selected patients.

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BACKGROUND: There are several techniques for harvesting the pedicled transverse rectus abdominis myocutaneous (TRAM) flap after mastectomy in breast cancer patients. We examined the whole muscle with partial sheath sparing technique and determined factors associated with its complications and oncological outcomes. METHODS: We retrospectively reviewed the results of 168 TRAM flaps performed between January 2003 and December 2010, focusing on complications and oncologic outcomes. RESULTS: Among the 168 pedicled TRAM flap procedures in 158 patients, flap complications occurred in 34%. Most of the flap complications included some degree of fat necrosis. There was no total flap loss. Flap complications were associated with elderly patients and the presence of major donor site complications. Abdominal bulging and hernia occurred in 12% of patients. The bi-pedicled TRAM flap and higher body mass index (BMI) were significant factors associated with increased donor site complications. Seven patients (4%) developed loco-regional recurrence. Within a median follow-up of 27 months, distant metastasis and death occurred in 6% and 4% of patients, respectively. CONCLUSIONS: The pedicled TRAM flap using the whole muscle with partial sheath sparing technique in the present study is consistent with the results from previous studies in flap complication rates and oncological outcomes.