Background:The management of advanced thyroid malignancies, particularly poorly differentiated thyroid carcinoma (PDTC), presents significant diagnostic and therapeutic challenges, especially when there is unusual bone involvement. While thyroid cancers typically do not exhibit local invasion to surrounding tissues until advanced stages, this case underscores the necessity for prompt diagnosis and a multidisciplinary approach to treatment to improve patient outcomes. The rarity of sternal infiltration by thyroid cancer and the complexities involved in surgical interventions highlight the need for awareness among healthcare professionals regarding potential diagnoses and treatment pathways. Case Description:We present the case of a 52-year-old male who presented with a painful, progressive anterior chest mass that was diagnosed as bone-infiltrating PDTC. Initial evaluations, including imaging and biopsies, revealed extensive infiltration of the sternum and surrounding structures originating from the thyroid gland. Following an interdisciplinary tumour board discussion, the patient underwent an en bloc resection of the thyroid gland along with affected chest structures and reconstruction with human acellular dermis. Postoperatively, he received radioactive iodine therapy. Despite initial management, follow-up imaging at six months indicated the emergence of bone metastases, prompting the initiation of external beam radiation therapy and recommendations for systemic treatment with a tyrosine kinase inhibitor. Conclusions:This case illustrates the diagnostic complexities and aggressive treatment required for advanced thyroid malignancies with rare bone involvement. Highlighting the importance of a timely and collaborative approach, it emphasizes that surgical intervention, while challenging, can still offer potential for local control in carefully selected patients. However, the case also serves as a reminder of the necessity for ongoing surveillance and the readiness to adapt treatment strategies in response to emerging metastatic disease, contributing to our understanding of management protocols for similar cases in clinical practice.

BACKGROUND:Intraoperative nerve monitoring (IONM) is widely used in endocrine surgery, yet substantial heterogeneity exists in its documentation, interpretation, and reporting. This limits comparability across studies and hampers the evaluation of clinical outcomes. METHODS:A consensus process was conducted by the European Society of Endocrine Surgeons (ESES), combining a systematic literature review, analysis of Eurocrine® registry data, a survey among ESES members, and a structured Delphi consensus process. RESULTS:Considerable variability was identified in monitoring techniques, signal interpretation, and outcome reporting. Key areas requiring standardization include the definition of loss of signal, documentation of neuromonitoring parameters, reporting of technical settings, and objective assessment of vocal cord function. Based on these findings, a set of consensus statements was developed to define minimum requirements for IONM research and reporting. CONCLUSION:This consensus statement provides a structured framework to improve standardization, data quality, and comparability in IONM research. Adoption of the recommendations may facilitate more robust evaluation of clinical outcomes and support future evidence generation in endocrine surgery.

Background: Calcitonin, a tumor marker primarily used to diagnose medullary thyroid carcinoma (MTC), can also be elevated in other conditions, complicating diagnosis. This study aims to provide a clinical evaluation of the real-world consequences of unexplained calcitonin elevation. Methods: We conducted a retrospective cohort study of patients with elevated basal calcitonin levels who presented at the Department of General, Visceral, and Transplantation Surgery, University Medical Center Mainz, between January 2015 and March 2025. Additionally, we reviewed electronic health records from 2007 onward for patients with ICD codes indicating calcitonin hypersecretion. Patients with confirmed MTC or genetic syndromes were excluded. Results: Of 345 patients with elevated calcitonin levels, 167 (48%) met the inclusion criteria, and 29 additional patients with calcitonin hypersecretion were identified via ICD, resulting in 167 patients analyzed. More than half of the patients were female (52%), had an average age of 53.9 years and a high prevalence of goiter (86%). Calcitonin levels were slightly elevated (<20 pg/mL) in 81% of cases and were above 50 pg/mL in only 10 patients. Surgery was performed in 77% of patients, mainly to exclude malignancy. Postoperatively, calcitonin normalized in 86% of patients but remained elevated in eight patients. Two of these patients were found to have false-positive results due to assay interference. Follow-up data were incomplete for a substantial proportion of patients, with a median follow-up of 4.6 months. The mortality rate was 4%, with causes unrelated to calcitonin levels. Conclusions: Elevated basal calcitonin levels, especially slightly elevated levels (<20 pg/mL), are common in clinical practice and often do not appear to be related to malignant disease, so careful investigation is required. Persistently elevated calcitonin levels justify further examinations, especially if other explanations can be ruled out. Only a few patients attend follow-up appointments, which makes patient follow-up challenging.

IntroductionThe use of artificial intelligence (AI) for TI-RADS classification in neck sonography for the assessment of thyroid nodules has been proven beneficial. We evaluated the learning curve of such AI in a real-world setting.MethodsBetween 03/2023 and 06/2024, 110 patients with 176 thyroid nodules were examined and classified according to ACR TI-RADS classification using 3D-ultrasound PIUR tUS Infinity software. After software training and update, the study was repeated examining 133 patients with 228 nodules (03/2023 until 10/2024). Every AI-based TI-RADS evaluation was compared to that of an experienced endocrine surgeon (assessor), unaware of the software results.ResultsFirst phase: AI-supported TI-RADS classification corresponded to the assessor's in 128/176 (73%) of examined nodules; second phase: correspondence in 210/227 (92.6%). Re-evaluating the initial 110 patients after software update, more nodules (194 vs. 176) were correctly assessed. In the first phase, AI "misinterpreted" in 36/176 (20%) cases nodules with microcalcifications or echogenic foci (leading to 1-3 points differences to accessor). After update, only 11/227 (4.8%) such nodules remained and relevant differences to the accessor were found in only 6/227 (2.6%) unusual cases (autoimmune thyroiditis, non-descended thymus, hemorrhaged cyst), compared to the initial 7%.ConclusionsAfter several rounds of deep learning, a significant improvement in correct ACR TI-RADS classification was demonstrated, especially the assessment of nodules within conglomerates. The AI-supported ultrasound is already a solid tool in the diagnosis of true thyroid nodules in non-inflamed tissue, but cannot yet replace an experienced clinician in complex or unusual cases; however, the fast learning curve is encouraging.

Neuroendocrine tumors have increased in prevalence and diversity in recent years and are often diagnosed at metastatic stages. Compared with nonradioactive systemic treatment with somatostatin analogs, peptide receptor radionuclide therapy (PRRT) has shown superior overall survival benefits for well-differentiated neuroendocrine tumor patients. This study aimed to identify biomarkers from 68Ga‒DOTATOC PET/CT scans to predict survival in patients treated with PRRT in the clinic. This retrospective study analyzed 68Ga-DOTATOC PET/CT data from 67 NET patients undergoing PRRT. Tumor volumes and SUV metrics were segmented using standardized protocols. Radiomics features from liver metastases were extracted and preprocessed for analysis. Data were analysed via Kaplan-Meier, Cox regression, and PCA to evaluate the prognostic value of volumetric-, radiomics-, and clinicopathological parameters. This study included scans from 67 patients with an average age of 67 years. The mean survival time was 46.5 months, with 43

BACKGROUND:Intraoperative neuromonitoring-that is, recording of electromyographic signals-is used routinely during (para)thyroid surgery. Surgeons label selected signals to document nerve identity, body side, and time point of stimulation (before or after resection), with a mislabelling rate of 20%. For the purpose of an automated error alert of mislabelled electromyographic signals, the authors developed a multitask one-dimensional convolutional neural network. METHODS:Raw intraoperative neuromonitoring data were corrected using MIONQA software. Labelled electromyographic signals were extracted and metadata (duration of surgery, timing, median electromyographic peak values of actual surgery) were added to each electromyographic wave. Between 150 and 280 extracted features were used to train, validate, and test various convolutional neural networks. RESULTS:Available raw data from a single centre including 1541 operations with continuous intraoperative nerve monitoring and 508 with intermittent intraoperative nerve monitoring between 2014 and 2024 were used. By repeated adjustments of the model architecture and the number of extracted features, an optimized one-dimensional convolutional neural network was designed. After multiple runs with randomized training (11 414 electromyograms) and test (4891) data, the final optimized convolutional neural network achieved a mean(standard deviation) accuracy of 95.72(0.76)% for correct identification of recurrent laryngeal, vagal, and superior laryngeal nerves; 97.68(0.72)% for correct prediction of the resected body side; and 97.61(0.89)% for correct identification of the stimulation time point (before versus after resection). The receiver operating characteristic curve for classification of the electromyographic peak signals had an excellent area under the curve of 0.993. CONCLUSION:The newly developed convolutional neural network enables accurate automated classification of electromyographic peak signals, facilitating the identification and correction of mislabelled intraoperative nerve monitoring data. Such optimized data quality is essential for artificial intelligence training, enabling neuromonitoring machines to alert the surgeon in the operating theatre of mislabelling. Future studies will aim to include a wider range of clinical scenarios and external data sets, in order to further optimize the existing labelling tool and allow clinical applications.

This case report describes the recurrence of an immature thyroid infiltrating teratoma in a female infant. Initially treated surgically for a cervical mass, the teratoma recurred, requiring further intervention. The case highlights the importance of multidisciplinary care and long-term follow-up in managing complex pediatric neoplasms.

The European Society of Endocrine Surgeons (ESES) was officially founded in Vienna in 2003, following discussions that began in the late 1990s. Its primary mission is to promote collaboration, research, and education in endocrine surgery across Europe. The society organizes biennial congresses and topic-specific conferences focused on guidelines and consensus statements. ESES has established partnerships with key organizations, including the Eurocrine Society, the Division of Endocrine Surgery (DES) of the European Union of Medical Specialists (UEMS), and the British Journal of Surgery Foundation, to enhance surgical standards, education, and research dissemination. In addition, ESES collaborates with various international endocrine surgery societies to further innovation and improve clinical outcomes. Recent initiatives include the accreditation of European surgical units as competence centers in endocrine surgery, ensuring high standards in training and practice. The field has seen transformative advancements, such as minimally invasive techniques, precision medicine, improved diagnostics, and multidisciplinary collaboration. These innovations were showcased at the 10th Biennial Congress of ESES in Rome in 2024, which marked the society's 20th anniversary and featured research presentations from international experts. This special issue of Updates in Surgery highlights key contributions from the congress, providing insight into the latest advancements shaping endocrine surgery.

Background: Papillary thyroid carcinoma (PTC) is the most common malignant tumor of the endocrine system. BRAF mutations occur in 40-60%, panRAS mutations in 10-15%, and different gene fusion events such as RET fusions in 7-35% of these neoplasms. Artificial intelligence (AI) methods could be used to predict genetic changes from conventional histopathological slides. Methods: In this retrospective study, we used two independent cohorts of patients with PTC, totaling 662 cases for the establishment of our AI pipeline. The Cancer Genome Atlas cohort (496 cases) served as the developmental cohort, while the Mainz cohort (166 cases) served as an independent external test cohort. BRAF, panRAS, and fusion status was determined for all of these patients as target variables. Vision Transformer was trained on digitized annotated hematoxylin and eosin-stained slides for the presence of these alterations. Highest probability image tiles were used to identify new morphological criteria associated with the genetic changes. Results: The trained model resulted in an area under the receiver operating characteristic curve of 0.882 (confidence interval 0.829-0.931) for BRAF, 0.876 (0.822-0.927) for panRAS, and 0.858 (0.801-0.912) for gene fusions. Accuracy was 79.3% (72.7-85.8%) for BRAF, 89.3% (84.2-94.0%) for panRAS, and 84.7% (78.8-90.2%) for gene fusions. The performance on the validation set was almost identical to that on the test set. Analyzing the highest predictive tiles, novel morphological criteria for fusion-associated PTC could be discovered. Conclusions: Our study demonstrates that predicting genetic alterations in digitized histopathological slides using AI is feasible in patients with PTC. Our model showed high accuracy in predicting these changes, making it potentially suitable for pre-screening. Explainability approaches uncovered previously undescribed morphological patterns associated with certain genotypes. Providing pathologists with these AI-based features could improve their accuracy. Assuming further positive prospective validation, this discovery could contribute to a deeper understanding of PTC.

Papillary thyroid cancer (PTC) is the most frequent malignant thyroid tumor in Germany. The diagnosis can only be confirmed by histological examination of the suspicious tissue. The clinical signs, sonographic findings, and the results of fine-needle aspiration, possibly supplemented by subsequent molecular genetic analysis, can confirm the suspected diagnosis before surgery. The prognosis is very good if the diagnosis is made early and, depending on the size of the tumor, complete surgical removal is achieved, with a 10-year survival rate of more than 90%; however, histologically PTC has several variants that are associated with either a high or low risk of metastases and recurrence in patients. Therefore, the extent of necessary treatment, in particular surgical interventions for PTC has been discussed for years. This article provides an overview of the current knowledge on the diagnosis, treatment and prognosis of PTC.

Thyroid surgery is associated with a risk of injury to the recurrent laryngeal nerve, especially in the presence of anatomical variants such as a non-recurrent laryngeal nerve (NRLN). Injury to the nerve leads to transient or permanent vocal cord palsy (VCP). A novel method to prevent VCP is continuous intraoperative nerve monitoring (cIONM), but less is known about the applicability of this method in patients with NRLN. The aim of this study was to evaluate our own data regarding feasibility and detailed characteristics of cIONM in NRLN patients. We performed a monocentric retrospective cohort analysis including clinical data and intraoperative nerve monitoring data (measured by Inomed Medizintechnik GmbH, Emmendingen, ‘C2’ and ‘C2 Xplore’ device) of all thyroid surgery patients, showing NRLN between 2014 and 2022. Of 1406 patients who underwent thyroid surgery with cIONM between 2014 and 2022, 12 patients (0.9%) showed NRLN intraoperatively. Notably, cIONM was feasible in eight patients (67%). In all cases the onset latency of the right vagus nerve was shorter (<3.0 ms) than usually expected, suggesting that a short latency might be suitable to distinguish NRLN. None of the patients had a post-operative VCP. Overall, cIONM appears to be feasible and safe in NRLN patients and provides helpful information to prevent VCP.

Abstract Background We hypothesized that - using intraoperative neuromonitoring (IONM) - a “prolonged” vagal latency at the beginning of (hemi)thyroidectomy is associated with an increased risk of recurrent laryngeal nerve (RLN) dysfunction when the patient’s body height is taken into account. Methods A single center retrospective data analysis of 1188 datasets for left and 1203 datasets for right thyroid procedures in 1490 patients was carried out. IONM data was merged with the respective clinical datasets recorded in the EUROCRINE® registry. Onset latency of the vagus nerve at the beginning of a procedure (V1) was analyzed for a correlation with postoperative RLN paresis. The patient’s height and other factors with potential impact on the vagal latency were analyzed to determine the threshold of a “prolonged” latency as indicator of nerve pre-damage. Results A positive correlation between patient body height and the V1 latency was identified. A significant difference of the V1 latency for patients with recorded RLN damage in comparison to patients without nerve damage was discovered (left: p=0.0003951, right: p=0.018). A prolonged left V1 latency is about 2.9 ms longer than the height-adjusted “normal” latency (regression analysis) and is associated with a higher risk of RLN paresis. Conclusions For the first time, it was proven that IONM latency is one of the indicators of an increased risk of RLN paresis in thyroid surgery. A table of “prolonged” left/right vagal latencies in correlation to patient body height is provided, alerting the surgeon to use extra caution or to change the operative strategy.

(1) Background: Infiltration of the aerodigestive tract in advanced thyroid carcinoma determines the prognosis and quality of life. Different stages of tracheal tumor invasion require customization of the surgical concept. (2) Methods: In the period from January 2007 to January 2023, patients who underwent surgery for advanced thyroid carcinomas with trachea resections were included in a retrospective observational study. The surgical resection concepts and operation-associated complications were documented. The overall survival and post-resection survival were analyzed. (3) Results: From 2007 to 2023, at the single-center UMC Mainz, 33 patients (15 female and 18 male) underwent neck surgery with trachea resections for locally advanced thyroid carcinomas. Of these, 14 were treated with non-transmural (trachea shaving) and 19 transmural trachea resections (9 “window” resections, 6 near-circular resections, 3 sleeve resections and 1 total laryngectomy with extramucosal esophageal resection). The two-year postoperative survival rate was 82.0 percent. The two-year recurrence-free survival rate was 75.0 percent (mean follow-up period: 29.2 months). (4) Conclusions: Tracheal resections for locally advanced tumor infiltration are feasible as an element of highly individualized treatment concepts.

European Society of Endocrine Surgeons consensus statement on Advanced Thyroid Cancer: Definitions and management

Background Angiosarcoma of the adrenal gland is a very rare malignant vascular neoplasm. The clinical symptoms are atypical or completely absent. Angiosarcomas of the adrenal gland are therefore often discovered incidentally, and the diagnosis is made histologically after resection.Case presentation A 46-year-old white Spanish male who was a previous smoker and nondrinker and was slightly overweight (92 kg, 176 cm, body mass index 29.7 kg/m2) with no relevant medical history presented to the internal medicine emergency department of our hospital with an unclear 12 cm tumor of the right adrenal gland. Prior to the computed tomography scan, he had had persistent evening fevers for 4 months and unintentional weight loss of 5 kg. The laboratory results showed anemia and an elevated C-reactive protein, but no hormone production. We performed an open adrenalectomy of the right adrenal gland. Finally, the histologic findings revealed an angiosarcoma of the adrenal gland.Conclusion Even though angiosarcomas of the adrenal gland are rare, the differential diagnosis of an angiosarcoma should be considered if a malignant tumor of the adrenal gland is suspected. Treatment decisions should be made on an interdisciplinary basis and preferably in a specialized center. Owing to the rarity of angiosarcomas of the adrenal gland, it is necessary to continue to share clinical experience to gain a better understanding of this particular tumor entity.

PURPOSE:Postoperative hypoparathyroidism (HypoPT) is one of the most feared complications after thyroid surgery. In most cases, HypoPT is transient, requiring temporary substitution with calcium and active vitamin D. The analysis was conducted to investigate how calcium and vitamin D substitution was managed in routine postoperative clinical practice after discharge from hospital. METHODS:From March 2015 to December 2023, patients with HypoPT after thyroidectomy at the university medical center (UMC) Mainz, were included in a retrospective study. The rate of continued prescription of calcium and vitamin D by external practitioners in relation to the PTH and calcium levels at the first postoperative outpatient visit at the outpatient clinic of the UMC Mainz was analyzed and critically discussed. RESULTS:Ninety-four of 332 patients (28.3%) were continuously prescribed with calcium/vitamin D supplements: 14 had PTH deficiency and hypocalcemia and 14 had normal/elevated PTH levels with hypocalcemia, 59 had PTH values below the normal range and normo- or hypercalcemia and 7 had normal or elevated PTH levels with normocalcemia. CONCLUSIONS:There are inconsistent procedures regarding the adjustment of the calcium and vitamin D substitution by the practices providing external follow-up treatment. To avoid iatrogenic suppression of PTH levels, high calcium load and potential affection of the kidney function, a reduction scheme should be actively recommended by thyroid surgeons.

Papillary thyroid carcinoma (PTC), the most common malignancy of follicular cell derivation, is generally associated with good prognosis. Nevertheless, it is important to identify patients with aggressive PTCs and unfavorable outcome. Molecular markers such as BRAFV600E mutation and TERT promoter mutations have been proposed for risk stratification. While TERT promoter mutations have been frequently associated with aggressive PTCs, the association of BRAFV600E mutation with increased recurrence and mortality is less clear and has been controversially discussed. The aim of the present study was to analyze whether differentially expressed genes can predict BRAFV600E mutations as well as TERT promoter mutations in PTCs. RNA sequencing identified a large number of differentially expressed genes between BRAFV600E and BRAFwildtype PTCs. Of those, AHNAK2, DCSTAMP, and FN1 could be confirmed in a larger cohort (n = 91) to be significantly upregulated in BRAFV600E mutant PTCs using quantitative RT-PCR. Moreover, individual PTC expression values of DCSTAMP and FN1 were able to predict the BRAFV600E mutation status with high sensitivity and specificity. The expression of TERT was detected in all PTCs harboring TERT promoter mutations and in 19% of PTCs without TERT promoter mutations. Tumors with both TERT expression and TERT promoter mutations were particularly associated with aggressive clinicopathological features and a shorter recurrence-free survival. Altogether, it will be interesting to explore the biological function of AHNAK2, DCSTAMP, and FN1 in PTC in more detail. The analysis of their expression patterns could allow the characterization of PTC subtypes and thus enabling a more individualized surgical and medical treatment.

BACKGROUND: Surgical education is highly dependent on intraoperative communication. Trainers must know the trainee's training level to ensure high-quality surgical training. A systematic preoperative dialogue (Educational Team Time Out, ETO) was established to discuss the steps of each surgical procedure. METHODS: Over 6 months, ETO was performed within a time limit of 3 minutes. Digital surveys on the utility of ETO and its impact on performance were conducted immediately after surgery and at the end of the study period among the staff of the participating disciplines (trainer, trainee, surgical nursing staff, anaesthesiologists, and medical students). The number of surgical sub steps performed was recorded and compared with the equivalent period one year earlier. RESULTS: ETO was performed in 64 of the 103 eligible operations (62%). Liver resection (n = 37) was the most frequent procedure, followed by left-sided colorectal surgery (n = 12), partial pancreaticoduodenectomy (n = 6), right-sided hemicolectomies (n = 5), and thyroidectomies (n = 4). Anaesthesiologists most frequently reported that ETO had a direct impact on their work during surgery (90.9%). The influence scores were 46.8% for trainees, 8.8% for trainers, 53.3% for surgical nursing staff and 66.6% for medical students. During the implementation of ETO, a trend towards more assisted sub steps in oncologic visceral surgery was seen compared to the corresponding period one year earlier (51% vs.40%; p = 0.11). CONCLUSION: ETO leads to improved intraoperative communication and more performed substeps during complex procedures, which increases motivation and practical training. This concept can easily be implemented in all surgical specialties to improve surgical education. ( J Surg Ed 80:1215-1220. & COPY; 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Renal hyperparathyroidism results from pathophysiologic changes induced and maintained by terminal renal failure. Surgical treatment is possible using various resection strategies. Aim of the work (research question): The aim of this work is to illustrate the indications, techniques and resection strategies for surgical treatment of renal hyperparathyroidism. Material and methods: National and international guidelines regarding the surgical treatment of renal hyperparathyroidism were analyzed. Furthermore, our own practical experience was integrated into the article. Results: While the indications for surgery according to the Surgical Working Group Endocrinology (CAEK) guidelines are given in cases of clinical impairment and renal hyperparathyroidism that cannot be controlled by medication, international guidelines additionally refer to the absolute parathyroid hormone level for deciding for surgery. Discussion: Individual patient consultation is necessary in the case of renal hyperparathyroidism in order to determine the right time for surgical treatment as well as the most suitable surgical technique, taking into account the individual risk profile and other therapeutic perspectives, including renal transplantation.

Background: Intraoperative neuromonitoring is widely used in thyroid and parathyroid surgery to prevent unilateral and especially bilateral recurrent nerve paresis. Reference values for amplitude and latency for the recurrent laryngeal nerve and vagus nerve have been published. However, data quality measures that exclude errors of the underlying intraoperative neuromonitoring (IONM) data (immanent software errors, false data labelling) before statistical analysis have not yet been implemented. Methods: The authors developed an easy-to-use application (the Mainz IONM Quality Assurance and Analysis tool) using the programming language R. This tool allows visualization, automated and manual correction, and statistical analysis of complete raw data sets (electromyogram signals of all stimulations) from intermittent and continuous neuromonitoring in thyroid and parathyroid surgery. The Mainz IONM Quality Assurance and Analysis tool was used to evaluate IONM data generated and exported from 'C2' and 'C2 Xplore' neuromonitoring devices (inomed Medizintechnik GmbH) after surgery. For the first time, reference values for latency and amplitude were calculated based on 'cleaned' IONM data. Results: Intraoperative neuromonitoring data files of 1935 patients consecutively operated on from June 2014 to May 2020 were included. Of 1921 readable files, 34 were excluded for missing data labelling. Automated plausibility checks revealed: less than 3 per cent device errors for electromyogram signal detection; 1138 files (approximately 60 per cent) contained potential labelling errors or inconsistencies necessitating manual review; and 915 files (48.5 per cent) were indeed erroneous. Mean(s.d.) reference onset latencies for the left vagus nerve, right vagus nerve, recurrent laryngeal nerve, and external branch of the superior laryngeal nerve were 6.8(1.1), 4.2(0.8), 2.5(1.1), and 2.1(0.5) ms, respectively. Conclusion: Due to high error frequencies, IONM data should undergo in-depth review and multi-step cleaning processes before analysis to standardize scientific reporting. Device software calculates latencies differently; therefore reference values are device-specific (latency) and/or set-up-specific (amplitude). Novel C2-specific reference values for latency and amplitude deviate considerably from published values.