COVID-2019 Alert

Information about the 2019 Novel Coronavirus. Read the latest >

Información sobre el coronavirus 2019 (COVID-19). Aprenda más >


Lisa Orloff, MD

  • Lisa Ann Orloff



Work and Education

Professional Education

UCLA David Geffen School Of Medicine Registrar, Los Angeles, CA, 06/01/1986


University of Washington, Seattle, WA, 06/24/1987


University of Washington, Seattle, WA, 06/24/1988

University of Washington, Seattle, WA, 6/30/1992


Mt Sinai Medical Center, Cleveland, OH, 5/1/1992

Board Certifications

Otolaryngology, American Board of Otolaryngology

All Publications

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



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


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

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., McIver, B., Vargas, S., Domnguez Ruiz-Tagle, J. M., Steward, D., Holsinger, F. C., Kandil, E., Williams, M. D., Cruz, F., Loyola, S., Solar, A., Roa, J. C., Leon, A., Droppelmann, N., Arias, T., Lobos, M., Kong, C. S., Busaidy, N., Grubbs, E. G., Graham, P. H., Stewart, J., Tang, A., Wang, J., Orloff, L. A., Hernrquez-Henrquez, M., Lagos, M., Wohllk, N., Diaz, R. E., Vliz, J., Horvath, E., Tala, H., Pineda, P., Arroyo, P., Vasquez, F., Osorio, M., Schacter, D., Franco, C., Medina, F., Traipe, E., Marin, L., Miranda, G., Bruce, E., Bracamonte Nole, M., Mena, N., Gonzalez, H. 2020


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 15institutions of which897(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 wasavailable 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 histopathologicalprofile 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 intwo independent andethnically 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., Yu, J., Onakoya, P. A., Aswani, J., Baidoo, K., Bogale, M., Cairncross, L., Cordes, S., Daniel, A., Diom, E., Maurice, M. E., Mohammed, G. M., Biadgelign, M. G., Kon, F. I., Itiere, A., Koch, W., Konney, A., Kundiona, I., Macharia, C., Mashamba, V., Moore, M. G., Mugabo, R. M., Noah, P., Omutsani, M., Orloff, L. A., Otiti, J., Randolph, G. W., Sebelik, M., Todsen, T., Twier, K., Fagan, J. J. 2020


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. 2020: 194599820922984


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

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., Brodsky, M. B., Wallace, S., Cameron, T. S., Chao, C., Orloff, L. A., Atkins, N. E., McGrath, B. A., Lazarus, C. L., Vogel, A. P., Brenner, M. J. 2020: 115


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

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-+
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


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): 171924

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


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): 26974


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

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): 64447


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

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


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


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


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): 188188


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


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): 161729


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): 83041
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


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): 486067

View details for DOI 10.1002/cncr.30925

View details for Web of Science ID 000417078600017

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


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


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

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


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

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., Satpathy, A. T., Rubin, A. J., Montine, K. S., Wu, B., Kathiria, A., Cho, S. W., Mumbach, M. R., Carter, A. C., Kasowski, M., Orloff, L. A., Risca, V. I., Kundaje, A., Khavari, P. A., Montine, T. J., Greenleaf, W. J., Chang, H. Y. 2017


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-m 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

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): 486067


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 PubMedID 28881423

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


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
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


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


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

Preoperative Imaging for Thyroid Cancer: Beyond Ultrasonography. JAMA otolaryngology-- head & neck surgery Orloff, L. A., Randolph, G. W. 2016; 142 (6): 51516

View details for PubMedID 26985777

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


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



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


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


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


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


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


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


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-?


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


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


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


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