Body Composition in Primary Hyperparathyroidism: A Potential Contributor to Weakness and Fatigue.

BACKGROUND: Primary hyperparathyroidism (PHPT) patients commonly report weakness and fatigue, though the underlying mechanisms are uncertain. Our purpose is to determine whether CT-derived muscle and adipose tissue metrics are associated with weakness and fatigue in PHPT patients. METHODS: For this retrospective study, cross-sectional muscle and adipose tissue metrics were derived from CTs in PHPT patients undergoing preoperative imaging within 1 year of parathyroid surgery. Skeletal muscle index (SMI) and visceral adipose tissue (VAT)/subcutaneous adipose tissue (SAT) ratio were calculated based on a single CT image at the level of the L3 vertebra. Established sex-specific SMI thresholds were used to define sarcopenia. Demographic and clinical data were collected from the electronic health record. When available, postoperative CT images were analyzed to assess for changes in body composition pre- and post-parathyroidectomy. RESULTS: The cohort comprised 53 PHPT patients (38 females, 15 males, mean age 61.4 years), of whom 24 (45%) reported weakness, 43 (81%) reported fatigue, and 31 (58%) met CT-based criteria for sarcopenia. Lower SMI was significantly associated with preoperative weakness in females but not males. For both weakness and fatigue, VAT/SAT ratios were higher in symptomatic females and lower in symptomatic males than their asymptomatic counterparts, though these differences were not statistically significant. In patients with postoperative CTs (n = 23), no significant changes in CT metrics were observed after parathyroidectomy. DISCUSSION: In females but not males with PHPT, subjective preoperative weakness was significantly associated with lower SMI. Effects of parathyroid hormone on skeletal muscle and visceral adiposity may differ by sex.

RadioGraphics Update: Parathyroid CT and Primary Hyperparathyroidism.

Editor's Note.-RadioGraphics Update articles supplement or update information found in full-length articles previously published in RadioGraphics. These updates, written by at least one author of the previous article, provide a brief synopsis that emphasizes important new information such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes.

Multidisciplinary Endocrine Tumor Board: Assessment of the Patient Experience.

Research surrounding tumor boards has focused on patient outcomes and care coordination. Little is known about the patient experience with tumor boards. This survey examined aspects of the patient experience for patients presented at our multidisciplinary endocrine tumor board (ETB). A 15-item survey was distributed via the online patient portal to patients over the age of 18 whose case had been discussed at our ETB over an 18-month period. Descriptive statistics were reported, and a Fisher's exact test was used to examine relationships between variables. A total of 47 patients completed the survey (46%). A majority (72%) report their provider explained what the ETB is, and 77% report being informed their case would be discussed. Most patients were satisfied their case was being discussed (72%). A number of patients did report moderate or severe anxiety knowing their case was being discussed (15%). Sixty-four percent of patients report the ETB recommendations were clearly explained; however, satisfaction with the recommendations was slightly lower (53%). Despite the somewhat low satisfaction with the recommendations, 75% of patients felt more confident in their treatment plan knowing their case was discussed. Finally, if given the chance, 66% responded that they would have been interested in participating in their own ETB discussion. This study provides some insight into the patient experience surrounding tumor board discussions. Overall, patients are satisfied when their case is discussed at ETB. Patients can also experience anxiety about these discussions, and many patients desire to be present for their own discussions.

Testing for Primary Hyperparathyroidism in 17,491 Patients With Hypercalcemia.

BACKGROUND: Primary hyperparathyroidism (PHPT) is underdiagnosed and associated with many adverse health effects. Historically, many hypercalcemic patients have not received parathyroid hormone (PTH) testing; however, underlying reasons are uncertain. Our goals are to determine the PTH testing rate among hypercalcemic individuals at a large academic health system and to assess for characteristics associated with testing versus not testing for PHPT to inform future strategies for closing testing gaps. METHODS: This retrospective study included adult patients with ≥1 elevated serum calcium result between 2018 and 2022. Based on the presence or absence of a serum PTH result, individuals were classified as "screened" versus "unscreened" for PHPT. Demographic and clinical characteristics of these groups were compared. RESULTS: The sample comprised 17,491 patients: 6567 male (37.5%), 10,924 female (62.5%), mean age 59 y. PTH testing was performed in 6096 (34.9%). Characteristics independently associated with the greatest odds of screening were 5+ elevated calcium results (odds ratio [OR] 5.02, P < 0.0001), chronic kidney disease (OR 3.63, P < 0.0001), maximum calcium >12.0 mg/dL (OR 2.48, P < 0.0001), and osteoporosis (OR 2.42, P < 0.0001). Characteristics associated with lowest odds of screening were age <35 y (OR 0.60, P < 0.0001), death during the study period (OR 0.68, P < 0.0001), age ≥85 y (OR 0.70, P = 0.0007), and depression (OR 0.84; P = 0.0081). CONCLUSIONS: Only 35% of hypercalcemic patients received PTH testing. Although the presence of PHPT-associated morbidity was generally associated with increased rates of screening, hypercalcemic patients with depression were 16% less likely to be tested.

Opportunistic CT Assessment of Parathyroid Glands: Utility of Radiologist-Recommended Biochemical Evaluation for Diagnosing Primary Hyperparathyroidism.

BACKGROUND. Existing gaps in primary hyperparathyroidism (PHPT) diagnosis and treatment have prompted calls for systemic change in the approach to this disease. One proposed change is opportunistic assessment for enlarged parathyroid glands on routine CT examinations, to target biochemical testing to individuals most likely to have un-diagnosed PHPT. OBJECTIVE. The purpose of our study was to assess the utility of a radiologist recommendation for biochemical testing in patients with a suspected enlarged parathyroid gland on routine CT for identifying previously undiagnosed PHPT. METHODS. This retrospective study included patients without known or suspected PHPT who underwent routine CT (i.e., performed for reasons other than known or suspected parathyroid disease) between August 2019 and September 2021 in which the clinical CT report included a radiologist recommendation for biochemical testing to evaluate for possible PHPT because of a suspected enlarged parathyroid gland. Neuroradiologists at the study institution included this recommendation on the basis of individual judgment without formal criteria. The EHR was reviewed to identify patients who underwent subsequent laboratory evaluation for PHPT. An endocrine surgeon used available laboratory results and clinical data to classify patients as having PHPT, secondary hyper-parathyroidism, or no parathyroid disorder independent of the CT findings. RESULTS. The sample comprised 39 patients (median age, 68 years; 20 women, 19 men) who received the radiologist recommendation for biochemical evaluation. Of these patients, 13 (33.3%) received the recommended biochemical evaluation. Of the 13 tested patients, three (23.1%) were classified as having PHPT, four (30.8%) as having secondary hyperparathyroidism, and six (46.2%) as having no parathyroid disorder. Thus, the number of patients needing to receive a radiologist recommendation for biochemical testing per correct PHPT diagnosis was 13.0, and the number of patients needing to undergo laboratory testing per correct PHPT diagnosis was 4.3. One of the three patients classified as having PHPT underwent surgical resection of the lesion identified by CT, which was shown on histopathologic evaluation to represent hypercellular parathyroid tissue. CONCLUSION. Radiologist recommendations for biochemical testing in patients with suspected enlarged parathyroid glands on routine CT helped to identify individuals with undiagnosed PHPT. CLINICAL IMPACT. Opportunistic assessment for enlarged parathyroid glands on routine CT may facilitate PHPT diagnosis.

Opportunistic Parathyroid Gland Assessment on Routine CT Could Decrease Morbidity from Undiagnosed Primary Hyperparathyroidism.

RATIONALE AND OBJECTIVES: Gaps in primary hyperparathyroidism diagnosis are well-documented. End-organ damage correlates with disease duration and often occurs before diagnosis. We hypothesize that opportunistic parathyroid gland assessment on routine CT could decrease existing diagnosis gaps. Our purpose is to assess for enlarged parathyroid glands on contrast-enhanced CT acquired prior to biochemical screening and subsequent development of related morbidity. MATERIALS AND METHODS: This retrospective study included consecutive patients with primary hyperparathyroidism undergoing parathyroidectomy with contrast-enhanced CT including the lower neck and upper chest acquired prior to biochemical screening. One neuroradiologist retrospectively evaluated all CTs for enlarged (estimated weight greater than 60 mg) parathyroid glands. Gold standard operative and pathology reports were correlated with CT findings, and medical records were reviewed for development of primary hyperparathyroidism-related comorbidities. RESULTS: The sample comprised 38 patients (30 women, 8 men, median age 60 years) with 70 CTs of interest. The neuroradiologist identified 32 putative enlarged parathyroid glands (median estimated weight 307 mg) in 29 (76%) patients on CTs predating biochemical screening by a median of 30 months. Putative enlarged parathyroid glands on CT corresponded to pathologically proven parathyroid lesions in 26 (90%) patients. Of 26 patients with retrospectively identified pathologically proven parathyroid lesions, 12 (46%) developed at least 1 renal, bone, or neurocognitive comorbidity between CT and subsequent biochemical screening. CONCLUSION: Enlarged parathyroid glands are frequently visible on routine CTs acquired years prior to primary hyperparathyroidism diagnosis. Biochemical screening based on enlarged glands could potentially prevent associated morbidity in almost half of such patients.

Opioid-Free Thyroid and Parathyroid Operations: Are Patients Satisfied With Pain Control?

BACKGROUND: The aim of this study was to evaluate pain control and patient satisfaction using an opioid-free analgesic regimen following thyroid and parathyroid operations. METHODS: Surveys were distributed to all postoperative patients following total thyroidectomy, thyroid lobectomy, and parathyroidectomy between January and April 2020. After surgery, patients were discharged without opioids except in rare cases based on patient needs and surgeon judgment. We measured patient-reported Numeric Rating Scale (NRS) pain scores and satisfaction categorically as either satisfied or dissatisfied. RESULTS: We received 90 of 198 surveys distributed, for a 45.5% response rate. After excluding neck dissections (n = 6) and preoperative opioid use (n = 4), the final cohort included 80 patients after total thyroidectomy (26.3%), thyroid lobectomy (41.3%), and parathyroidectomy (32.5%).The majority reported satisfaction with pain control (87.5%) and the entire surgical experience (95%). A similar proportion of patients reported satisfaction with pain control after total thyroidectomy (90.9%), thyroid lobectomy (90.5%), and parathyroidectomy (80.8%), indicating the procedure did not significantly impact satisfaction with pain control (P = .47). Patients who reported dissatisfaction with pain control were more likely to receive opioid prescriptions (30% vs 2.9%, P < .01), but the majority still reported satisfaction with their entire operative experience (70%). DISCUSSION: Even with an opioid-free postoperative pain regimen, most patients report satisfaction with pain control after thyroid and parathyroid operations, and those who were dissatisfied with their pain control generally reported satisfaction with their overall surgical experience. Therefore, an opioid-free postoperative pain control regimen is well tolerated and unlikely to decrease overall patient satisfaction.

Value of Old Imaging for Patients Undergoing Parathyroidectomy for Primary Hyperparathyroidism.

INTRODUCTION: Although imaging plays no role in diagnosing primary hyperparathyroidism (PHPT), preoperative localization is essential for a focused parathyroidectomy. We hypothesized that reviewing imaging obtained prior to PHPT diagnosis can identify enlarged parathyroid glands and provide information that might potentially impact the preoperative evaluation and intraoperative course of patients undergoing parathyroidectomy. METHODS: We included adult patients with PHPT who underwent parathyroidectomy between October 2015 and October 2020 and had contrast-enhanced computed tomography (CT) imaging of the lower neck and upper chest obtained prior to diagnosis for unrelated indications. A radiologist reviewed the prediagnosis CTs blinded to subsequent parathyroid localization imaging and operative findings. A surgeon assessed the radiologist's findings in the context of each case to determine the potential impact of information from old imaging on surgical decision-making. RESULTS: We identified at least one enlarged parathyroid gland on prior contrast-enhanced CT in 30 (75%) of 40 included patients. Despite old imaging enabling correct localization, 60% of these 30 underwent dedicated parathyroid imaging prior to parathyroidectomy. Knowledge of the enlarged parathyroid(s) on prior imaging might have allowed a more focused approach in 10.0% and prompted a more thorough exploration in 13.3%. In the total cohort, reviewing prior imaging could have provided information capable of changing the preoperative evaluation in 52.5% and the operative course in 17.5%. CONCLUSIONS: The identification of enlarged parathyroid glands on contrast-enhanced CT imaging that predates a diagnosis of PHPT is possible. Prospective studies might verify the impact of these findings on the preoperative evaluation and operative course of patients undergoing parathyroidectomy.

A multi-institutional study evaluating and describing atypical parathyroid tumors discovered after parathyroidectomy.

Objective: To describe common intraoperative and pathologic findings of atypical parathyroid tumors (APTs) and evaluate clinical outcomes in patients undergoing parathyroidectomy. Methods: In this multi-institutional retrospective case series, data were collected from patients who underwent parathyroidectomy from 2000 to 2018 from three tertiary care institutions. APTs were defined according to the AJCC eighth edition guidelines and retrospective chart review was performed to evaluate the incidence of recurrent laryngeal nerve injury, recurrence of disease, and disease-specific mortality. Results: Twenty-eight patients were identified with a histopathologic diagnosis of atypical tumor. Mean age was 56 years (range, 23-83) and 68% (19/28) were female. All patients had an initial diagnosis of primary hyperparathyroidism with 21% (6/28) exhibiting clinical loss of bone density and 32% (9/28) presenting with nephrolithiasis or renal dysfunction. Intraoperatively, 29% (8/28) required thyroid lobectomy, 29% (8/28) had gross adherence to adjacent structures and 46% (13/28) had RLN adherence. The most common pathologic finding was fibrosis 46% (13/28). Postoperative complications include RLN paresis/paralysis in 14% (4/28) and hungry bone syndrome in 7% (2/28). No patients with a diagnosis of atypical tumor developed recurrent disease, however there was one patient that had persistent disease and hypercalcemia that is being observed. There were 96% (27/28) patients alive at last follow-up, with one death unrelated to disease. Conclusion: Despite the new AJCC categorization of atypical tumors staged as Tis, we observed no recurrence of disease after resection and no disease-specific mortality. However, patients with atypical tumors may be at increased risk for recurrent laryngeal nerve injury and incomplete resection.

Molecular Testing for Indeterminate Thyroid Nodules: Association of Negative Predictive Value With Nodule Size.

BACKGROUND: Molecular testing helps stratify risk of malignancy in indeterminate thyroid nodules, but it may be limited in its ability to rule out malignancy in large nodules. METHODS: We compared small thyroid nodules (<4 cm) to large thyroid nodules (4 cm or greater) in a retrospective, single center, cohort study of indeterminate thyroid nodules analyzed with ThyroSeq from 10/2015 through 4/2020. Our primary outcome was negative predictive value. RESULTS: A total of 204 thyroid nodules were analyzed with ThyroSeq and 62 underwent resection allowing comparison to final pathology for 48 small nodules and 14 large nodules. A greater proportion of large nodules were observed in men (50.0% vs 18.8% in small nodules, P = .02), but median age was similar between the groups (49.0 vs 52.5 years, P = .95). False negative results comprised a higher proportion of tests for large nodules (14.3%) than small nodules (0%, P = .01). The negative predictive value of ThyroSeq in small nodules was 1 indicating a negative test reliably predicted a benign nodule, compared to .5 in large nodules indicating a negative test in this cohort was reliable in predicting benignity. Applying the same negative predictive value to the cohort of large nodules that did not undergo resection after negative molecular testing (n = 16), it is possible that 8 large thyroid malignancies were missed at our institution during the study period. CONCLUSIONS: Large thyroid nodules are associated with a higher rate of false negative results and a lower negative predictive value during molecular analysis of indeterminate thyroid nodules.

Inguinal Hernia Repairs on the Chief's Service: A Safe Educational Model in Resident Entrustment.

OBJECTIVE: We hypothesized that a Chief Resident Service educational model provides safe care for patients compared to that received on standard academic services where rotating residents adopt the practices and preferences of their attending. DESIGN: We retrospectively identified patients undergoing inguinal hernia repairs from July 2016 through June 2019 and matched Chief's service patients to standard academic service patients 1:1 on CPT, sex and age. We compared patient characteristics, recurrence rates, outcomes and complications. SETTING: Tertiary care center, single institution. PARTICIPANTS: Overall, 77 patients undergoing inguinal hernia repairs (66% open and 34% laparoscopic) on the Chief's service matched successfully to 77 standard academic service patients during the study period. RESULTS: Age, BMI and ASA were similar between the services, but Chief's service patients were less likely to be current smokers (1.3% vs. 24.7%) and more likely to be former smokers (59.7% vs. 26.0%) than standard academic service patients (p < 0.01). Patients presenting with incarcerated hernias (5.2% vs. 9.1%), recurrent (10.4% vs. 5.2%) and bilateral hernias (19.5% vs. 10.4%) were similar between the Chief's service and standard academic services, respectively (all p > 0.05). Operative times were longer for the Chief's service for open (123 min vs. 67, p < 0.01) and laparoscopic (112 min vs. 79, p = 0.02) repairs. Recurrence rates (6.5% vs. 3.9%, p = 0.47) and complications including infection, seroma or hematoma requiring evacuation and need for reoperation were similarly low (p > 0.05) between the Chief's and standard academic services, respectively. Despite low complication rates, Chief's service patients were more likely to present to the ED post-op (14.3% vs. 1.3%; p = 0.001), but readmission rates were similarly low (2.6% vs. 0%, p = 0.09). CONCLUSIONS: Providing general surgery chief residents with a supervised opportunity to direct, plan and provide surgical care in clinic and the operating room, as a transition to independent practice following graduation, is safe for patients presenting with inguinal hernias. Concerns about patient safety should not be a barrier to maximizing entrustment for the evaluation and operative management of select core general surgery diagnoses and operations.

Parathyroid 4D CT in Primary Hyperparathyroidism: Exploration of Size Measurements for Identifying Multigland Disease and Guiding Biochemically Successful Parathyroidectomy.

BACKGROUND. In patients with primary hyperparathyroidism (PHPT), bilateral neck exploration is necessary for multigland disease (MGD), whereas minimally invasive parathyroidectomy is often preferred for single-gland disease (SGD). An existing system (the 4D-CT MGD score) for differentiating SGD from MGD with the use of preoperative parathyroid CT considers the size of only the largest candidate lesion. OBJECTIVE. The purpose of this study was to assess the utility of the size of the second-largest lesion on parathyroid CT for differentiating SGD from MGD as well as the utility of individual gland size for predicting the need for surgical removal and to derive optimal size thresholds for these purposes. METHODS. This retrospective study included patients with PHPT who underwent biochemically successful parathyroidectomy after preoperative parathyroid CT. Clinical radiology reports were reviewed to classify reported candidate parathyroid lesions as low-, intermediate-, or high-confidence lesions. Resected hypercellular parathyroid lesions were correlated with clinically reported candidate lesions. Patients were classified as having SGD or MGD on the basis of operative and pathology reports, independent of CT findings. One observer retrospectively determined the estimated volume (0.52 × length × width × height) and maximum diameter of clinically reported high-confidence lesions, as well as the 4D-CT MGD scores from the examinations. Diagnostic performance was assessed. RESULTS. The sample comprised 62 patients (41 women, 21 men; median age, 65 years), 47 of whom had SGD and 15 of whom had MGD, with 151 candidate lesions, including 106 high-confidence lesions. Based on the second-largest high-confidence lesions, an estimated volume threshold of 60 mm3 or greater achieved 53% sensitivity and 96% specificity, whereas a maximum diameter threshold of 7 mm or greater achieved 67% sensitivity and 96% specificity for MGD; a 4D-CT MGD score of 3 or greater achieved 47% sensitivity and 68% specificity for MGD. For predicting the need to remove a gland for successful parathyroidectomy, an estimated volume threshold of 114 mm3 or greater achieved 84% sensitivity and 97% specificity, and a threshold of 55 mm3 or greater achieved 93% sensitivity and 87% specificity; a maximum diameter threshold of 7 mm or greater achieved 93% sensitivity and 84% specificity. CONCLUSION. The estimated volume and maximum diameter of high-confidence candidate lesions can differentiate SGD from MGD and identify individual glands requiring removal for successful parathyroidectomy. Differentiating SGD from MGD may be aided by considering both the first- and second-largest high-confidence lesions. CLINICAL IMPACT. The findings will help identify patients who are likely to require bilateral neck explorations, informing preoperative patient counseling and individualized operative planning.

Enlarged Parathyroid Glands on Trauma Computed Tomography: Frequency and Assessment for Possible Primary Hyperparathyroidism.

OBJECTIVES: The aims of the study were to determine the frequency of enlarged parathyroid glands among patients undergoing trauma computed tomography (CT) who fall within the typical primary hyperparathyroidism (PHPT) age range and to assess for evidence of PHPT. METHODS: For this retrospective study of 336 emergency department patients, concurrent cervical spine CT and neck CT angiography (CTA) examinations were reviewed for visible parathyroid glands. When visible, estimated weight was calculated, and a PHPT likelihood category was assigned after medical record review. RESULTS: At least 1 parathyroid gland was visible in 17 patients (5%) and enlarged (estimated weight > 60 mg) in 11 (3%). Patients classified as "highly likely" or "likely" of having PHPT exhibited larger glands (median, 355 mg) than those classified as "unlikely" or "highly unlikely" (median, 47 mg; P = 0.01). CONCLUSIONS: Parathyroid glands were enlarged in 3% of our cohort. Although PHPT likelihood seems to increase with gland size, definitive determination requires both serum calcium and serum parathyroid hormone.

Outcomes Following Cholecystectomy on a Service Designed to Maximize Chief Resident Entrustment.

BACKGROUND: The chief resident service provides surgical trainees in their final year of training the opportunity to maximize responsibility, continuity, and decision-making. Although supervised, chief residents operate according to personal preferences instead of adapting to their attendings' preferences. We hypothesized that outcomes following cholecystectomy are equivalent between the chief resident service and standard academic services. METHODS: We matched adults undergoing cholecystectomy from 07/2016-06/2019 on the chief resident service to two standard academic service patients based on operative indication and age. We compared demographics, operative details, and 30-d complications. RESULTS: This study included 186 patients undergoing cholecystectomy. Body mass index (32.4 versus 32.0, P = 0.49) and Charlson comorbidity index (0.9 versus 1.4, P = 0.16) were similar between chief resident and standard academic services, respectively. Operative approach was similar (95.2% laparoscopic on chief resident service versus 94.4% on standard service), but residents on the chief resident service performed cholangiograms more often (48.4% versus 22.6%, P < 0.01) and averaged longer operative times during laparoscopic cholecystectomy with cholangiogram (146±28 versus 85±22 min, P < 0.01) and without (94±31 versus 76±35 min, P < 0.01) compared with standard academic services, respectively. 30-d complication rates were similar (5.2% chief resident versus 5.0% standard, P = 0.95). No patients suffered bile leak, bile duct injury, or reoperation. Emergency Department visits were similar (12.1% chief resident versus 7.4% standard, P = 0.32); readmissions were less frequent on the chief resident service (0.0% versus 5.0% standard, P = 0.03). CONCLUSIONS: With appropriate supervision, chief residents provide safe care for patients undergoing cholecystectomy while directing medical decisions and practicing according to their preferences.

Multiple endocrine neoplasia 2A presenting in a family with a history of Hirschprung's disease.

Hirschprung's disease co-occurs with multiple endocrine neoplasia type 2A infrequently but at a higher rate with certain RET mutations. We present a case of a patient evaluated for an adrenal incidentaloma with a history of familial Hirschprung's. Our patient was found to have synchronous pheochromocytoma and medullary thyroid carcinoma illustrating the importance of genetic testing in these patients to determine appropriate screening for endocrine tumors.