Progression of Nodular Thyroid Disease in Familial Adenomatous Polyposis Syndrome: Refined Surveillance Recommendations.

BACKGROUND: Patients with familial adenomatous polyposis (FAP) have an increased risk of thyroid nodular disease. Previous studies demonstrated that screening thyroid ultrasound (US) will allow detection of nodules in 38% and thyroid cancer in 2.6% of patients. The aim of this study is to define the value of serial US evaluation at identifying disease progression in patients with FAP. METHODS: Retrospective review from 2008 to 2023 at a single referral center. All patients with FAP and screening thyroid US were included. Patient demographics, initial US characteristics, follow-up regarding the development of new nodules and cancer were assessed using a Kaplan-Meier analysis. RESULTS: A total of 556 patients underwent screening. Fifty percent were male. Median age at first screening was 38 year old. Eighty percent underwent longitudinal follow-up for a median length of 7 years. At initial screening, 169 patients (30%) had nodules. For patients with normal baseline US, 14% developed a nodule overtime. A total of 20 patients (3.6%) were diagnosed with thyroid cancer. The cumulative incidence of initial and subsequent cancer was 4% by 5 years and 6% by 10 years, while the cumulative incidence of thyroid nodules was 40% and 48%, respectively. CONCLUSIONS: Based on the Kaplan-Meier analysis, ongoing longitudinal screening is warranted for patients with FAP as they are prone to thyroid cancer and nodule development overtime even when presenting with a baseline normal US. Additionally, these data demonstrate a slow development of thyroid cancer from a normal US, thus it is reasonable to consider selectively extending the screening interval for this population.

Laparoscopic versus robotic adrenalectomy in severely obese patients.

BACKGROUND: Over the last 20 years, the prevalence of severe obesity (body mass index ≥ 35 kg/m2) has almost doubled. This condition increases the challenge of laparoscopic adrenalectomy (LA) by creating problems with instrument reach, adequate exposure, and visualization. The aim was to compare perioperative outcomes of laparoscopic versus robotic adrenalectomy (RA) in severely obese patients. METHODS: This was an institutional review board-approved retrospective study. Prospectively collected clinical parameters of patients who underwent LA versus RA between 2000 and 2021 at a single center were compared using Mann-Whitney U, ANOVA, Chi-square, and multivariate regression analysis. Continuous data are expressed as median (interquartile range). RESULTS: For lateral transabdominal (LT) adrenalectomies, skin-to-skin operative time (OT) [164.5 (71.0) vs 198.8 (117.0) minutes, p = 0.006] and estimated blood loss [26.2 (15.0) vs 72.6 (50.0) ml, p = 0.010] were less in RA versus LA group, respectively. Positive margin rate, hospital stay and 90-day morbidity were similar between the groups (p = NS). For posterior retroperitoneal (PR) approach, operative time and perioperative outcomes were similar between LA and RA groups. Multivariate analysis demonstrated robotic versus laparoscopic technique (p = 0.006) to be an independent predictor of a shorter OT. CONCLUSION: There was a benefit of robotic over the laparoscopic LT adrenalectomy regarding OT and estimated blood loss. Although limited by the small sample size, there was no difference regarding perioperative outcomes between RA and LA performed through a PR approach.

Outcomes of Thyroidectomy During the COVID-19 Pandemic: A NSQIP Analysis.

BACKGROUND: The coronavirus disease 19 (COVID-19) has had a profound impact on our healthcare system. Surgery in particular faced significant challenges related to allocation of resources and equitable patient selection, resulting in a delay in non-emergent procedures. We sought to study the impact of the COVID-19 pandemic on patient outcomes after thyroidectomy. METHODS: This was a cross-sectional study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database that included all thyroidectomies from 2018 to 2020. The primary outcome evaluated was surgical outcomes during 2020, the first year of the pandemic, compared to years preceding the pandemic. Factors associated with adverse postoperative outcomes during the study period were included in a multivariate analysis. RESULTS: The volume of thyroidectomy procedures in 2020 decreased 16.4% when compared to the preceding years. During 2020, there was a significant increase in mortality (0.14% vs. 0.07%, p = 0.03), unplanned intubation (0.45% vs. 0.27%, p < 0.01) and cardiac arrest (0.11% vs. 0.03%, p < 0.01), while other complications remained stable. Undergoing surgery in 2020 remained as a risk factor for mortality in a multivariate analysis (OR 2.4 95% CI 1.3-4.4). CONCLUSION: The first year of the COVID-19 pandemic had a significant impact on outcomes after thyroidectomy resulting in increased mortality. As the world recovers, there will likely be an increase number of patients seeking care who were unable to obtain it during the pandemic. Close attention should be placed on the outcomes which were altered during the pandemic.

A Modern Assessment of Cancer Risk in Adrenal Incidentalomas: Analysis of 2219 Patients.

OBJECTIVE: The aim of this study was to analyze the incidence of and risk factors for adrenocortical carcinoma (ACC) in adrenal incidentaloma (AI). SUMMARY OF BACKGROUND DATA: AI guidelines are based on data obtained with old-generation imaging and predominantly use tumor size to stratify risk for ACC. There is a need to analyze the incidence and risk factors from a contemporary series. METHODS: This is a retrospective review of 2219 AIs that were either surgically removed or nonoperatively monitored for ≥12 months between 2000 and 2017. Multivariate logistic regression was performed to define risk factors. ROC curves constructed to determine optimal size and attenuation cut-offs for ACC. RESULTS: 16.8% of AIs underwent upfront surgery and rest initial nonoperative management. Of conservatively managed patients, an additional 7.7% subsequently required adrenalectomy. Overall, ACC incidence in AI was 1.7%. ACC rates by size were 0.1%, 2.4%, and 19.5% for AIs of <4, 4 to 6, and >6 cm, respectively. The optimal size cut-off for ACC in AI was 4.6 cm. ACC risks by Hounsfield density were 0%, 0.5%, and 6.3% for lesions of <10, 10 to 20, and >20 HU, with an optimal cut-off of 20 HU to diagnose ACC. 15.5% of all AIs and 19.2% of ACCs were hormonally active. Male sex, large tumor size, high Hounsfield density, and >0.6 cm/year growth were independent risk factors for ACC. CONCLUSION: This contemporary analysis demonstrates that ACC risk per size in AI is less than previously reported. Given these findings, modern management of AIs should not be based just on size, but a combination of thorough hormonal evaluation and imaging characteristics.

Laparoscopic versus robotic adrenalectomy in pheochromocytoma patients.

BACKGROUND AND OBJECTIVES: Pheochromocytoma is a challenging tumor type requiring resection with a clear margin and an intact capsule to prevent recurrences. Our aim was to compare perioperative outcomes of laparoscopic adrenalectomy (LA) versus robotic adrenalectomy (RA) for pheochromocytoma. METHODS: In an institutional review board-approved retrospective study, clinical parameters of patients who underwent LA versus RA at a single center were compared using Mann-Whitney U, χ2 , and survival analyses. Continuous data are expressed as median (interquartile range). RESULTS: There was a total of 157 patients (RA: n = 87, LA: n = 70) analyzed. Estimated blood loss (36.3 [35.0] vs. 99.9 [65.0] cc, p = 0.020) and hospital stay (1.3 [0.0] vs. 2.2 [1.0] days, p = 0.010) were lower in robotic versus laparoscopic group, respectively. Disease-free and overall survival was similar between groups. The rate of conversion to open for tumors ≥5 cm was less in the robotic group (0% vs. 14%, respectively, p = 0.048). CONCLUSION: In this study, long-term outcomes of LA and RA were similar, although adrenalectomies performed robotically were associated with less blood loss, shorter hospital stay, and a lower chance of conversion to open in the case of large tumors.

Preoperative Calcium and Parathyroid Hormone Values Are Poor Predictors of Gland Volume and Multigland Disease in Primary Hyperparathyroidism: A Review of 2000 Consecutive Patients.

OBJECTIVE: Calcium and parathyroid hormone (PTH) values are believed to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland size, with higher values predicting single-gland disease. In this modern series, these preoperative values were correlated with operative findings to determine their utility in predicting the gland involvement at parathyroid exploration. METHODS: Two thousand consecutive patients who underwent initial surgery for sporadic primary hyperparathyroidism from 2000 to 2014 were reviewed. All patients underwent a 4-gland exploration. Relationships between preoperative calcium and PTH values with the total gland volume of each patient were examined and stratified using the number of involved glands: single adenoma (SA), double adenoma (DA), and hyperplasia (H). RESULTS: There were 1274 (64%) SA, 359 (18%) DA, and 367 (18%) H cases. There was a poor correlation between preoperative calcium and PTH values (R = 0.37) and both poorly correlated with the total gland volume (R < 0.40). Similarly, subgroup analysis using the number of involved glands showed poor correlation. The mean total gland volume was similar among all subgroups (SA = 1.28 cm3, DA = 1.43 cm3, and H = 1.27 cm3; P = .52), implying that individual glands were smaller in multigland disease. SA was found in 271 (53%) of patients with calcium levels of ≤10.5 mg/dL and 122 (78%) with levels of ≥12 mg/dL (P < .001). CONCLUSION: This is the largest series correlating preoperative calcium and PTH values with operative findings of gland size and number of diseased glands. Although a lower calcium value predicts somewhat more multigland disease, the overall poor correlation should make the parathyroid surgeon aware that gland size and multigland disease cannot be predicted by preoperative laboratory testing.

Intraoperative near-infrared imaging of parathyroid glands: A comparison of first- and second-generation technologies.

BACKGROUND: Intraoperative near-infrared imaging (NIFI) of parathyroid glands (PG) by first-generation technology had limited image quality and depth penetration. Second-generation NIFI has recently been introduced. Our aim was to compare (1) capability to detect PG and (2) image quality between older and newer technologies. METHODS: Accurately detecting PG, as well as, quality of autofluorescence (AF) was compared between an older charge-coupled device (CCD) camera and a newer complementary metal-oxide semiconductor (CMOS). χ2 , t test, and analysis of variance were used for analysis. RESULTS: There were 300 patients who underwent parathyroidectomy (PTX) and/or thyroidectomy (THY) with NIFI, 200 with CCD, and 100 with CMOS. Although both NIFI technologies detected >94% of PG, CMOS was superior to CCD. Comparing AF quality, mean pixel intensity of PG compared with the background was higher with CMOS compared with CCD. When comparing PG detected by NIFI before visual identification by a surgeon, both CCD and CMOS had similar results (25% vs. 22%; p = .3). CONCLUSION: Both NIFI cameras were excellent at detecting PG. Second-generation NIFI (CMOS) displayed higher detection rates and AF intensity. Although surgeons identified majority of PG before NIFI detection, 25% of PG were identified with NIFI first, suggesting future advancements of this technology may expand its applications during parathyroid/thyroid operations.

Outcomes of laparoscopic tumor ablation for neuroendocrine liver metastases: a 20-year experience.

BACKGROUND: Since neuroendocrine tumors have an indolent behavior, studies looking at oncologic outcomes should report a long-term follow-up. Over the years, we have been treating selected patients with neuroendocrine liver metastases (NELM) with laparoscopic ablation (LA) and reported favorable local tumor control. The aim of this study is to see whether this local efficacy translates into long-term oncologic outcomes. METHODS: This was an IRB-approved study of patients who underwent LA for NELM at a single center. Overall and progression-free survivals were analyzed using Kaplan-Meier and Cox proportional hazards model. RESULTS: Study included 58 women and 71 men with a median age of 58 (IQR 47-67) years. Tumor type included carcinoid (n = 92), pancreatic islet cell (n = 28), and medullary thyroid cancer (n = 9). There was a median of 6 (IQR 3-8) tumors, measuring 1.6 (IQR 1.1-2.4) cm. At a median follow-up of 73 (IQR 34-135) months, local liver recurrence per patient, new liver recurrence, and new extrahepatic recurrence rates were 22, 68, and 33%, respectively. Local tumor recurrence per lesion was 5% (n = 42/770). Median overall survival was 125 months, with 5-year, and 10-year overall survivals being, 76%, and 59%, respectively; and median disease-free survival was 13 months, with 5-year, and 10-year progression-free survivals being 26%, and 6%, respectively. On Cox proportional hazards model, overall survival was independently predicted by tumor size, grade, and resection status of primary. CONCLUSION: To our knowledge, this is the largest single-center experience with the longest follow-up regarding the utilization of LA for NELM. Our results demonstrate that in selected patients, LA achieves a 95% local tumor control and 59% 10-year overall survival.

Need for Completion Thyroidectomy in Patients Undergoing Lobectomy for Indeterminate and High-Risk Nodules: Impact of Intra-Operative Findings and Final Pathology.

INTRODUCTION: Current guidelines increasingly suggest the use of thyroid lobectomy for indeterminate (Bethesda 3 and 4) and high-risk (Bethesda 5 and 6) thyroid nodules; however, the clinical reality is often very different. MATERIALS AND METHODS: The aim of this study was to determine the rate of completion thyroidectomy (CTx) for indeterminate and high-risk thyroid nodules which are pre-operatively classified as suitable for unilateral resection (lobe eligible) based on current guidelines. Seven hundred consecutive patients with thyroid nodules and FNA cytology over four years (2015-2018) were reviewed. RESULTS: Distribution of the dominant nodules by Bethesda was: non-diagnostic 3.9%, benign 28.1%, atypia of unknown significance 19.0%, follicular neoplasm 23.6%, suspicious for malignancy 6.1% and malignancy 19.3%. Of 298 indeterminate nodules, 68.8% (205/298) had relative but independent indications for a total thyroidectomy (TTx) and the remainder were candidates for lobectomy. For these lobe eligible patients, the overall risk of ultimately needing a TTx was 19.4% (18/93), comprising 4.3% (4/93) from intra-operative findings and 15.7% (14/89) from final pathology. Similarly, of 170 high-risk nodules, 63.5% (108/170) had upfront indications for a TTx and the remaining 62 nodules were lobe eligible. Of the patients taken to the operating room for a lobectomy, 21.0% (13/62) were upgraded to a TTx intra-operatively and 26.5% (13/49) post-operatively. The lobe success rate for indeterminate nodules was 25.2% and for high-risk nodules was 21.2%. The rate of CTx, or the proportion of patients needing a second operation was 15.7% (14/89) and 26.5% (13/49), respectively. CONCLUSIONS: In counselling a patient for surgery, the risk of needing a more radical initial procedure or second surgery needs to be accurately explained. There are three points of care that can influence operative strategy, pre-operatively by way of high-risk clinical factors, intra-operatively via anatomical findings and post-operatively in response to unrecognized pathological features. Additionally, the patient's personal value judgment and level of risk aversion should be taken into consideration.

CRYOPRESERVATION OF PARATHYROID TISSUE: A WHITE PAPER ON ESTABLISHING A LOCAL SERVICE.

Objective: Preservation of parathyroid function is one of the primary tenets of endocrine surgery. For patients with thyroid disease, an inadvertently compromised parathyroid gland is routinely autotransplanted into the neck at the time of surgery. By contrast, for patients with parathyroid disease secondary to hyperplasia, the timing of auto-transplantation needs to be further considered in order to balance the risks between persistent disease and permanent hypocalcemia. Cryopreservation preserves cellular function and permits the storage of parathyroid tissue for potential re-implantation at a later date in patients who develop hypoparathyroidism. Methods: In this paper, we review the process of cryopreservation, with particular emphasis on the regulatory issues involved in establishing a local service, tissue processing, billing and reimbursements, outcome (functionality), and complications. Results: A detailed description of the technique as performed at our institution is described and illustrated. Conclusion: Cryopreservation affords surgical insurance against the disastrous sequelae of permanent hypoparathyroidism. Our techniques are easy to adopt with only a modest initial investment of time and money, particularly for institutions that already cryopreserve other tissue types. Abbreviations: PTH = parathyroid hormone; RMPI = Roswell Park Memorial Institute; RPMI-SSS = RPMI-serum substitute supplement.

RECEIVER OPERATING CHARACTERISTIC ANALYSIS OF INTRAOPERATIVE PARATHYROID HORMONE MONITORING TO DETERMINE OPTIMUM SENSITIVITY AND SPECIFICITY: ANALYSIS OF 896 CASES.

Objective: While intraoperative parathyroid hormone (IOPTH) monitoring with a ≥50% drop commonly guides the extent of exploration for primary hyperparathyroidism (pHPT), receiver operating characteristic (ROC) analysis has not been performed to determine whether other criteria yield better sensitivity and specificity. The aim of this study was to identify the optimum percent change of IOPTH following removal of the abnormal parathyroid pathology, in order to predict biochemical cure. Secondary aims were to identify patient subgroups with increased area under the ROC curve (AUC) and the need for moderated criteria. Methods: A retrospective review was performed on patients undergoing primary parathyroid surgery for sporadic pHPT between 1999 and 2010 at a tertiary center for endocrine surgery. Eight hundred and ninety-six patients with primary hyperparathyroidism were included. Multigland disease (MGD) was defined as the intraoperative detection of more than 1 enlarged hypercellular gland or persistent disease after single gland excision. ROC analysis was used to determine the value with the best performance at predicting MGD, following bilateral exploration. Results: MGD was diagnosed in 174 patients (19.4%). ROC analysis demonstrated an AUC of 0.69. An IOPTH drop of 72% was the point of optimal discrimination with a sensitivity of 55% and specificity of 76% for predicting MGD. Subgroup analysis by preoperative calcium, preoperative PTH, localization studies, or pre- and post-excision IOPTH, did not identify any factors associated with an improved AUC. Conclusion: To our knowledge, this is the first study to use ROC analysis in a large patient cohort. An IOPTH drop of 72% was found to have optimal discriminating ability. We failed to identify a subset of patients for whom there was substantial improvement in the AUC, sensitivity, or specificity. Abbreviations: AUC = area under the ROC curve; BE = bilateral neck exploration; FE = focal parathyroid exploration; IOPTH = intraoperative parathyroid hormone; MGD = multigland disease; MIBI = Tc99m-sestamibi I-123 subtraction single-photon emission computed tomography/computed tomography; pHPT = primary hyperparathyroidism; ROC = receiver operating characteristic; SGD = single gland disease; US = surgeon-performed neck ultrasound.

CALCIUM CREATININE CLEARANCE RATIO IS NOT HELPFUL IN DIFFERENTIATING PRIMARY HYPERPARATHYROIDISM FROM FAMILIAL HERPERCALCEMIC HYPOCALCIURIA: A STUDY OF 1000 PATIENTS.

OBJECTIVE: With increasing recognition of more subtle presentations of primary hyperparathyroidism (pHPT), laboratory values are frequently seen in a range that would be expected for patients who have familial hypercalcemic hypocalciuria (FHH). Calcium creatinine clearance ratio (CCCR) has been advocated as a diagnostic tool to differentiate between these two disorders. However, it is limited by an indeterminate range (0.01-0.02). The aim of this study is to assess the relevance of CCCR in a modern series of patients with surgically managed pHPT. METHODS: We performed a retrospective cohort study of 1000 patients who underwent parathyroid surgery for pHPT over eleven years. CCCR was evaluated by degree of biochemical derangement, single versus multiple gland disease and interfering medications. RESULTS: Patient demographics and resected histopathology were typical for a current series of patients with pHPT. In retrospect, none of the patients were suspected to have FHH post operatively. CCCR was less than 0.01 for 19.0%, between 0.01-0.02 for 43.7% and greater than 0.02 in 37.3%. Distribution of CCCR for patients free from interfering medications and different histological subtypes were the same. One third of the cohort had mild calcium elevations, more typical for FHH. Of these, almost two thirds had a CCCR in a range suspect for FHH (<0.02). CONCLUSION: To our knowledge this is the largest series to evaluate the validity of CCCR for patients with surgically confirmed pPHT. The utility of CCCR in screening for FHH is limited, as 63% of modern patients with confirmed pHPT have low values.

Use of Calcium and Parathyroid Hormone Nomogram to Distinguish Between Atypical Primary Hyperparathyroidism and Normal Patients.

BACKGROUND: The diagnosis of primary hyperparathyroidism (1°HP) has become more complex, as fewer patients present with classic phenotype of concomitant elevation of calcium and parathyroid hormone (PTH). In addition, the distinction between normal versus abnormal patients is challenging, with an increasing number of patients with 1°HP, who have calcium and/or PTH values within the "reference" range. Patients with "inappropriately" elevated PTH values relative to their serum calcium are considered to have 1°HP. METHODS: The study population consisted of 1753 patients with pathologically proven 1°HP and 74 healthy control patients. Nomograms were created by plotting PTH versus calcium of the two groups. The 95 % confidence zone of calcium and PTH for normal individuals was plotted and compared to patients with 1°HP. RESULTS: The comparison of control and disease groups showed a clear demarcation zone on the plots of calcium versus PTH. In the group of 1°HP, 70 % had classic 1°HP presentation with the concomitant elevation of both calcium (≥10.5 mg/dL) and PTH (≥65 pg/dL). 21 % had "normocalcemic" HP with calcium ≤10.5 mg/dL and PTH ≥65 pg/dL. 6 % had "normohormonal" HP with calcium ≥10.5 mg/dL and PTH ≤65 pg/dL. 3 % had both calcium and PTH within the reference range. 68.5 % of patients had single adenoma, 16 % double adenoma, and 15.5 % hyperplasia. CONCLUSION: This nomogram serves as a diagnostic tool to distinguish normal patients from those with 1°HP, particularly those with atypical presentations. This recognition would permit previously observed patients to benefit from curative surgery.

Value of Prophylactic Cervical Thymectomy in Parathyroid Hyperplasia.

BACKGROUND: In parathyroid hyperplasia (HPT), parathyroid glands within the cervical thymus are a cause for recurrence. As a result of differences in pathophysiology, variable practice patterns exist regarding performing bilateral cervical thymectomy (BCT) in primary hyperplasia versus hyperplasia from renal failure or familial disease. The objective of this study was to capture patients where thymic tissue was found with subtotal parathyroidectomy (PTX) and intended BCT, identify number of thymic supernumerary glands (SNGs), and determine overall cure rate. METHODS: Retrospective review of patients with four-gland exploration and intended BCT for HPT from 2000 to 2013 was performed. Identification of thymic tissue and SNGs were determined by operative/pathology reports. Univariate analysis identified differences in cure rate for patients undergoing subtotal PTX with or without BCT. RESULTS: Thymic tissue was found in 52 % of 328 primary HPT (19 % unilateral, 33 % bilateral), 77 % of 128 renal HPT (28 % unilateral, 49 % bilateral), and 100 % of familial HPT (24 % unilateral, 76 % bilateral) patients. Nine percent of primary, 18 % of renal, and 10 % of familial HPT patients had SNGs within thymectomy specimens. Cure rates of primary HPT patients with BCT were 99 % compared to 94 % in subtotal PTX alone. Renal HPT cure rates were 94 % with BCT compared to 89 % without BCT. CONCLUSIONS: Renal HPT patients benefited most in cure when thymectomy was performed. Although the rate of SNGs found in primary HPT was lower than renal HPT, the cure rate mimicked the pattern in renal disease. Furthermore, the incidences of SNGs in primary and familial HPT were similar. On the basis of these data, we advocate that BCT be considered in primary HPT when thymic tissue is readily identified.

Factors affecting the surgical approach and timing of bilateral adrenalectomy.

BACKGROUND: Laparoscopic adrenalectomy has gained widespread acceptance. However, the optimal surgical approach to laparoscopic bilateral adrenalectomy has not been clearly defined. The aim of this study is to analyze the patient and intraoperative factors affecting the feasibility and outcome of different surgical approaches to define an algorithm for bilateral adrenalectomy. METHODS: Between 2000 and 2013, all patients who underwent bilateral adrenalectomy at a single institution were selected for retrospective analysis. Patient factors, surgical approach, operative outcomes, and complications were analyzed. RESULTS: From 2000 to 2013, 28 patients underwent bilateral adrenalectomy. Patient diagnoses included Cushing's disease (n = 19), pheochromocytoma (n = 7), and adrenal metastasis (n = 2). Of these 28 patients, successful laparoscopic adrenalectomy was performed in all but 2 patients. Twenty-three out of the 26 adrenalectomies were completed in a single stage, while three were performed as a staged approach due to deterioration in intraoperative respiratory status in two patients and patient body habitus in one. Of the adrenalectomies completed using the minimally invasive approach, a posterior retroperitoneal (PR) approach was performed in 17 patients and lateral transabdominal (LT) approach in 9 patients. Patients who underwent a LT approach had higher BMI, larger tumor size, and other concomitant intraabdominal pathology. Hospital stay for laparoscopic adrenalectomy was 3.5 days compared to 5 and 12 days for the two open cases. There were no 30-day hospital mortality and 5 patients had minor complications for the entire cohort. CONCLUSIONS: A minimally invasive operation is feasible in 93% of patients undergoing bilateral adrenalectomy with 65% of adrenalectomies performed using the PR approach. Indications for the LT approach include morbid obesity, tumor size >6 cm, and other concomitant intraabdominal pathology. Single-stage adrenalectomies are feasible in most patients, with prolonged operative time causing respiratory instability being the main indication for a staged approach.

The utility of neck ultrasound and sestamibi scans in patients with secondary and tertiary hyperparathyroidism.

INTRODUCTION: Secondary hyperparathyroidism (SHPT) and tertiary hyperparathyroidism (THPT) are disease entities in patients with chronic kidney disease that are caused by parathyroid hyperplasia. The role of preoperative localization studies in patients undergoing parathyroidectomy for these conditions remains poorly defined. AIM: To evaluate the utility of surgeon-performed neck ultrasound (US) as well as sestamibi scans in the localization of parathyroid glands in patients with SHPT/THPT. MATERIALS AND METHODS: A retrospective analysis of patients with SHPT/THPT who underwent parathyroidectomy at a single institution. Results of preoperative localization studies were compared to intraoperative findings. RESULTS: One hundred and three patients underwent parathyroidectomy for SHPT/THPT. All patients underwent surgeon-performed neck US, while 92 (89%) underwent sestamibi scans. US failed to localize any of the parathyroids in 4 patients (3.8%), while sestamibi was negative in 11 (12%). Forty-seven ectopic glands were identified in 38 patients in whom sestamibi was performed. In five patients (13%), ectopic glands were identified by both modalities, by US only in 6 (16%), by sestamibi only in 8 (21%), and by neither study in 19 patients (50%). US showed new thyroid nodules in 19 patients (18.4 %), leading to lobectomy or thyroidectomy at the time of parathyroidectomy in 16 patients (15.5%). Pathology showed malignancy in 7 patients (6.8%). CONCLUSION: US and MIBI offer little benefit in localizing ectopic glands and rarely change the conduct of a standard four-gland exploration. Although there was a benefit of US in the assessment of thyroid nodules, in only 8.7% of patients was sestamibi of benefit in identifying ectopic glands.

CIRCULATING THYROID-STIMULATING HORMONE RECEPTOR MESSENGER RNA AS A MARKER OF TUMOR AGGRESSIVENESS IN PATIENTS WITH PAPILLARY THYROID MICROCARCINOMA.

BACKGROUND: We have previously shown that thyroid-stimulating hormone receptor messenger RNA (TSHR mRNA) is detectable in the peripheral blood of patients with papillary thyroid microcarcinoma (PTmC). The aim of this study was to analyze the utility of TSHR mRNA status as a marker of tumor aggressiveness in patients with PTmC. METHODS: Preoperative TSHR mRNA values were obtained in 152 patients who underwent thyroidectomy and were found to have PTmC on final pathology. Clinical parameters were analyzed from an institutional review board-approved database using χ(2) and t tests. RESULTS: Preoperatively, TSHR mRNA was detected in the peripheral blood in 46% of patients, which was less than that for macroscopic papillary thyroid carcinoma (PTC) (80%) but higher than for benign thyroid disease (18%) (P<.001). The focus of cancer was larger in the TSHR mRNA-positive group compared to the negative group (0.41 vs. 0.30 cm, respectively, P = .015). The prevalence of tall-cell variant was higher in the TSHR mRNA positive group. The rates of lymph node (LN) metastasis (16% vs. 10%), multifocality (46% vs. 49%), and extra-thyroidal extension (10% vs. 5%) were similar between the TSHR mRNA-positive and-negative groups, respectively. In patients 45 years or older, rate of LN metastasis was higher in those who were TSHR mRNA positive (10%) versus negative (2%) (P = .039). TSHR mRNA positivity predicted a higher likelihood of radioactive iodine treatment (36% vs. 17%, P = .009) postoperatively. CONCLUSION: This study shows that TSHR mRNA, which is a marker of circulating thyroid cancer cells, is detectable in about half of patients with PTmC. The positivity of this marker predicts a higher likelihood of LN involvement in patients with PTmC who are 45 years or older.

A critical analysis of postoperative morbidity and mortality after laparoscopic radiofrequency ablation of liver tumors.

BACKGROUND: Although the laparoscopic approach provides certain advantages over the percutaneous radiofrequency thermal ablation (RFA), the morbidity needs to be defined. The aim of this study is to analyze the morbidity and underlying risk factors after laparoscopic RFA of liver tumors. METHODS: Between 1996 and 2012, 910 patients underwent 1,207 RFA procedures for malignant liver tumors in a tertiary academic center. The 90-day morbidity and mortality were extracted from a prospective IRB-approved database. Statistical analyses were performed using regression, t, and χ (2) tests. RESULTS: Complications occurred in 50 patients (4 %) and were gastrointestinal in 13 patients (1.1 %), infections in 10 (0.8 %), hemorrhagic in 9 (0.7 %), urinary in 7 (0.6 %), cardiac in 4 (0.3 %), pulmonary in 3 (0.3 %), hematologic in 2 (0.2 %), and neurologic in 2 (0.2 %). The complication rates for an RFA done alone (5 %) versus concomitantly with ancillary procedure (6 %) were similar (p = .6). In all patients who developed postoperative bleeding from the liver, the ablations had been performed on lesions located in the right posterior sector. Of 9 patients with bleeding, 5 (55 %) required a laparotomy. Also, 60 % of liver abscesses occurred in patients with a prior bilioenteric anastomosis (BEA). The 90-day mortality was 0.4 % (n = 5). Hospital stay was 1.2 ± 0.1 days and was prolonged to 4.4 ± 0.3 days in case of complications. CONCLUSIONS: This study describes the morbidity and mortality to be expected after a laparoscopic RFA procedure. Our results show that additional caution should be used to prevent bleeding complications in patients with tumors located in the right posterior sector and infections in patients with a history of BEA.

Biochemical and radiological relationships in patients with pheochromocytoma: lessons from a case control study.

BACKGROUND: An elevation of fractionated plasma or urinary metanephrine (MN) or nor-metanephrine (NMN), collectively called metanephrines (MN and NMN), >4-fold above the upper limit of normal (ULN) is usually considered to be diagnostic for pheochromocytoma (PHEO). There are a greater number of false positive results when the elevations are more modest. AIM: To identify biochemical and radiological features in PHEOs with modest elevations (<4-fold above ULN) of metanephrines. METHODOLOGY: We retrospectively reviewed the charts of 112 patients with PHEO (10% extra-adrenal) and 208 patients with a non-PHEO adrenal mass operated from 1997-2011, who had metanephrines measured pre-operatively. We divided PHEO into group 1 (n = 90) with metanephrines ≥4-fold ULN and group 2 (n = 22) with metanephrines <4-fold ULN. The non-PHEO group was designated as group 3. RESULTS: The median (range) tumour size in group 1 and group 2 was 4·8 cm (1·7-22) and 3·0 cm (1·7-5) respectively (P < 0·001). All patients with PHEO in group 2 had a tumour <5 cm in size. The MN fraction was elevated in about 65% of groups 1 and 2; only 2 (1%) patients in group 3 had an elevated urinary MN fraction, and none were associated with an elevated plasma MN fraction. All PHEOs had a pre-contrast attenuation ≥17 Hounsfield Units (HU). CONCLUSIONS: Modest elevations (<4-fold ULN) of the NMN fraction in an adrenal mass >5 cm are almost always falsely positive. Elevations in plasma and urinary MN fraction are less likely to be false positive. The CT pre-contrast attenuation of PHEOs is >10 HU.

The utility of intraoperative ultrasound in modified radical neck dissection: a pilot study.

BACKGROUND: Although the value of surgeon-performed neck ultrasound (SPUS) for thyroid nodules has been validated, the utility of intraoperative ultrasound (US) in modified radical neck dissection (MRND) has not been reported in the literature. The aim of this study was to analyze the utility of intraoperative SPUS in assessing the completeness of MRND for thyroid cancer. METHODS: Between 2007 and 2011, a total of 25 patients underwent MRND by 1 surgeon for thyroid cancer. All patients underwent intraoperative SPUS, which was repeated at the end of the neck dissection (completion US) to look for missed lymph nodes (LNs). RESULTS: There were 10 male and 15 female patients. Pathology included 23 papillary and 2 medullary carcinomas. The number of LNs removed per case was 23 ± 2, and the number of positive was LNs 5 ± 1. In 4 (16%) cases, intraoperative US detected 7 residual LNs, which would have been missed, if completion US were not done. These missed LNs were located in low-level IV (3 nodes), high-level II (2 nodes), and posterior level V (2 nodes) and measured 1.4 ± 0.2 cm. At follow-up, recurrence was seen in 2 (8%) patients, including a superior mediastinal recurrence in a patient with tall cell cancer and a jugular LN recurrence at level II in another patient with papillary thyroid cancer. CONCLUSION: This pilot study shows that intraoperative SPUS can help assess the completeness of MRND. According to our results, intraoperative completion US identifies LNs missed by palpation 16% of the time.