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.

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.

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.

Complementary use of resection and radiofrequency ablation for the treatment of colorectal liver metastases: an analysis of 395 patients.

BACKGROUND: Liver resection and radiofrequency ablation (RFA) are two surgical options in the treatment of patients with colorectal liver metastases (CLM). The aim of this study was to analyze patient characteristics and outcomes after resection and RFA for CLM from a single center. METHODS: Between 2000 and 2010, 395 patients with CLM undergoing RFA (n = 295), liver resection (n = 94) or both (n = 6) were identified from a prospective IRB-approved database. Demographic, clinical and survival data were analyzed using univariate and multivariate analyses. RESULTS: RFA patients had more comorbidities, number of liver tumors and a higher incidence of extrahepatic disease compared to the Resection patients. The 5-year overall actual survival was 17 % in the RFA, 58 % in the Resection group (p = 0.001). On multivariate analysis, multiple liver tumors, dominant lesion >3 cm, and CEA >10 ng/ml were independent predictors of overall survival. Patients were followed for a median of 20 ± 1 months. Liver and extrahepatic recurrences were seen in 69 %, and 29 % of the patients in the RFA, and 40 %, and 19 % of the patients in the Resection group, respectively. CONCLUSIONS: In this large surgical series, we described the characteristics and oncologic outcomes of patients undergoing resection or RFA for CLM. By having both options available, we were able to surgically treat a large number of patients presenting with different degrees of liver tumor burden and co-morbidities, and also manage liver recurrences in follow-up.

Robotic transaxillary endocrine surgery: a comparison with conventional open technique.

BACKGROUND: Robotic transaxillary (RT) endocrine surgery may improve cosmetic outcomes. We report our initial experience in RT thyroid and parathyroid surgery and the associated learning curve, and compare early surgical outcomes to those of open thyroidectomy (OT) and focal parathyroidectomy (FP). METHODS: A prospective database review identified patients who had undergone RT endocrine surgery. A case-matched group who underwent OT or FP was also identified. Demographics, histopathology, operative outcomes, and follow-up data were collected. Groups were compared using Student's t test and the χ(2) test. RESULTS: Fifteen RT procedures were performed: 11 RT thyroidectomies (6 total, 5 lobectomies) and 4 RT parathyroidectomies (2 focal, 2 unilateral), representing 5.9% and 2.2% of thyroidectomies and parathyroidectomies performed. The OT group contained 16 patients (13 totals, 3 lobectomies). The FP group contained 12 patients. There was no significant difference in age, gender, BMI, pathology, or complications between the groups. Mean operating time was significantly longer in the RT group (232 vs. 109 min, P = 0.0002) as was mean incision length (6 vs. 3.6 cm, P < 0.0001). No RT procedures were converted and no major complications occurred. Operating time decreased significantly over consecutive cases demonstrating a learning curve. CONCLUSIONS: RT thyroidectomy and parathyroidectomy can be performed safely by specialist endocrine surgeons, early in their learning curve, without an increased complication rate, albeit with significantly longer operating times.

A new classification of positive sestamibi and ultrasound scans in parathyroid localization.

BACKGROUND: Ultrasound (US) and sestamibi (MIBI) are traditionally considered positive or negative. The purpose of this study was to define and test a new scoring system for MIBI and US and to determine whether this can improve their accuracy for primary hyperparathyroidism. METHODS: This is a prospective study of 200 consecutive patients with primary hyperparathyroidism who had a single uptake on MIBI scans before bilateral neck exploration at a tertiary academic center between 2007 and 2008. These patients also had surgeon-performed neck US in the office, which was scored as "typical" or "atypical" based on how characteristic the image resembled a parathyroid gland. The MIBI uptake was scored by the nuclear medicine specialist as "weak," "moderate," or "strong" compared with the signal intensity of the thyroid. US and MIBI scoring was done preoperatively and their findings were compared with operative data. RESULTS: Of 200 patients, 71 % had a single adenoma, 12 % had double adenomas, and 17 % had four-gland hyperplasia. A weak, moderate, and strong signal on MIBI had an accuracy of 23, 47, and 72 %, respectively, in demonstrating single-gland disease. An atypical versus typical US appearance was accurate in 55 and 74 % of the time, in identifying single-gland disease. CONCLUSIONS: An appraisal of US and MIBI positivity in relation to image characteristics affects the reliability of both studies. This information should be kept in mind when selecting patients for focal neck exploration.

A critical analysis of laparoscopic and open approaches to sporadic pancreatic insulinoma resection in the modern era.

BACKGROUND: A single center experience with sporadic pancreatic insulinoma was analyzed to develop an algorithm for modern surgical management. METHODS: Thirty-four patients undergoing surgery from 2001 to 2019 were reviewed. RESULTS: The majority underwent enucleation (10 laparoscopic, 15 open). Laparoscopy was performed in 22 patients with conversion to open in 11, mostly related to the proximity of the tumor to the pancreatic duct (n = 4). Tumors on the anterior and posterior surface of the pancreas in all anatomic locations were completed with laparoscopic enucleation. Overall, the clinically-relevant postoperative pancreatic fistula (CR-POPF) rate was 21%, with no difference between laparoscopic versus open enucleation (10% vs 20%, p = 0.50) or enucleation versus resection (16% vs 33%, p = 0.27). Laparoscopic enucleation had shorter median hospital length of stay (LOS) compared with open (4 vs 7 days, p = 0.02). CONCLUSIONS: Laparoscopic enucleation does not increase the CR-POPF risk and provides an advantage with a shorter hospital LOS in select patients. Tumor location and relationship to the pancreatic duct guide surgical decision-making. These findings highlight tumor-specific criteria that would benefit from a minimally invasive approach.

Use of Preoperative Imaging in Primary Hyperparathyroidism.

CONTEXT: Preoperative imaging is performed routinely to guide surgical management in primary hyperparathyroidism, but the optimal imaging modalities are debated. OBJECTIVE: Our objectives were to evaluate which imaging modalities are associated with improved cure rate and higher concordance rates with intraoperative findings. A secondary aim was to determine whether additive imaging is associated with higher cure rate. DESIGN, SETTING, AND PATIENTS: This is a retrospective cohort review of 1485 adult patients during a 14-year period (2004-2017) at an academic tertiary referral center that presented for initial parathyroidectomy for de novo primary hyperparathyroidism. MAIN OUTCOME MEASURES: Surgical cure rate, concordance of imaging with operative findings, and imaging performance. RESULTS: The overall cure rate was 94.1% (95% confidence interval, 0.93-0.95). Cure rate was significantly improved if sestamibi/single-photon emission computed tomography (SPECT) was concordant with operative findings (95.9% vs. 92.5%, P = 0.010). Adding a third imaging modality did not improve cure rate (1 imaging type 91.8% vs. 2 imaging types 94.4% vs. 3 imaging types 87.2%, P = 0.59). Despite having a low number of cases (n = 28), 4-dimensional (4D) CT scan outperformed (higher sensitivity, specificity, positive predictive value, negative predictive value) all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas. CONCLUSIONS: Preoperative ultrasound combined with sestamibi/SPECT were associated with the highest cure and concordance rates. If pathology was not found on ultrasound and sestamibi/SPECT, additional imaging did not improve the cure rate or concordance. 4D CT scan outperformed all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas, but these findings were underpowered.

Recognition of primary hyperparathyroidism: Delayed time course from hypercalcemia to surgery.

BACKGROUND: Under recognition of primary hyperparathyroidism can lead to delays in diagnosis and surgical management. We aimed to establish a time course for primary hyperparathyroidism from initial hypercalcemia to surgery and evaluate the impact of guidelines for surgical referral on this time course. METHODS: A retrospective review was conducted on all patients undergoing parathyroidectomy for primary hyperparathyroidism in 2013 at the Cleveland Clinic. Patients were stratified by adherence to 2008 indications for surgery guidelines, age, calcium values, osteoporosis, history of nephrolithiasis, 24-hour urinary calcium values, and estimated glomerular filtration rate. RESULTS: 219 patients with sporadic primary hyperparathyroidism underwent initial surgery. Twenty-three (10.5%) normocalcemic patients were excluded. Time course from initial hypercalcemia to surgery was 3.9 years for 137 (70%) patients who met objective guideline criteria versus 3.8 years for 59 (30%) patients who did not meet objective guideline criteria (P = .87). Stratification by age <50 years and calcium value >11.5 mg/dL revealed earlier times to surgery. However, osteoporosis, nephrolithiasis, 24-hour urinary calcium values, and estimated glomerular filtration rate had no impact. CONCLUSION: There is a delayed time course for patients with sporadic primary hyperparathyroidism from initial hypercalcemia to surgery. Despite published objective criteria, one third of the patients who underwent surgery did not meet criteria, signifying the importance of clinician and patient decision making. Furthermore, patients with osteoporosis and nephrolithiasis who can significantly benefit from surgical cure have no apparent impact on the time to surgery. Overall, the objective guideline criteria have no effect in referral patterns suggesting a call for revision.

Importance of surgeon-performed ultrasound in the preoperative nodal assessment of patients with potential thyroid malignancy.

INTRODUCTION: A comprehensive cervical ultrasound evaluation is essential in the operative planning of patients with thyroid disease. Reliance on radiographic reports alone may result in incomplete operative management as pathologic lymph nodes are often not palpable and evaluation of the lateral neck is not routine. This study examined the role of surgeon-performed ultrasound in the evaluation of patients who underwent lateral neck dissection for thyroid cancer. METHODS: We conducted a retrospective review of a prospectively maintained database of patients who underwent therapeutic lymph node dissection for thyroid cancer between 2001 and 2016 at our tertiary referral center. All patients had surgeon-performed ultrasound preoperatively by 1 of 7 endocrine surgeons. These findings were compared with prereferral imaging studies to determine the value of surgeon-performed ultrasound to their overall treatment. RESULTS: Of 92 patients who underwent thyroidectomy with lateral neck dissection, 97% had prereferral imaging of the neck (ultrasonography, computed tomography, positron emission tomography). Of these patients, nodal disease was suggested by computed tomography scanning in 70.8% and by ultrasonography in 54%. Of all patients, 45% had positive lateral neck nodes detected only on surgeon-performed ultrasound despite prior neck imaging. Nodal disease was identified in 50% of patients with only 1 study and 50% of patients with greater than 1 study before surgeon-performed ultrasound. Of patients with nodes detected by surgeon-performed ultrasound, only 67% had a prereferral diagnosis of thyroid cancer. CONCLUSIONS: Our data demonstrate that reliance on standard preoperative imaging alone would have led to an incorrect initial operation in 45% of our patients. Awareness of the limitations of prereferral imaging is important for surgeons treating patients with thyroid and parathyroid disease. Surgeon-performed ultrasound is a useful tool in the diagnosis and accurate staging of patients.

Laparoscopic radiofrequency ablation of neuroendocrine liver metastases: a 10-year experience evaluating predictors of survival.

BACKGROUND: A decade ago we reported the first use of laparoscopic radiofrequency thermal ablation (RFA) for the treatment of neuroendocrine hepatic metastases. This study analyzes our 10-year experience and determines characteristics predictive of survival. METHODS: Eighty RFA sessions were performed in 63 patients with neuroendocrine hepatic metastases in a prospective trial. All patients had unresectable disease with computed tomography (CT) documented lesion and/or symptom progression. Perioperative morbidity, symptom relief, disease progression, and long-term survival were analyzed. Data are expressed as mean +/- standard error of the mean (SEM). RESULTS: There were 22 women and 41 men, age 54.4 +/- 1.5 years followed for 2.8 +/- 0.3 years (range, 0.1 to 7.8). Tumor types included 36 carcinoid, 18 pancreatic islet cell, and 9 medullary thyroid cancer. RFA was performed 1.6 +/- 0.3 years after the diagnosis of liver metastases. Number of lesions treated was 6 +/- 0.5 (range, 1 to 16). Forty-nine patients underwent 1 ablation session, and 14 (22%) had repeat sessions caused by disease progression. Mean hospital stay was 1.1 days. Perioperative morbidity was 5%, with no 30-day mortality. Fifty-seven percent of patients exhibited symptoms. One week postoperatively 92% of these reported at least partial symptom relief, and 70% had significant or complete relief. Duration of symptom control was 11 +/- 2.3 months. CT follow-up demonstrated 6.3% local tumor recurrence. Larger dominant liver tumor size and male gender adversely impacted survival (P < .05). Median survival times were 11.0 years postdiagnosis of primary tumor, 5.5 years postdiagnosis of neuroendocrine hepatic metastases, and 3.9 years post-1st RFA. Survival for patients undergoing repeat ablation sessions was not significantly lower. CONCLUSIONS: This study represents the largest series of neuroendocrine hepatic metastases treated by RFA. In this group of patients with aggressive neuroendocrine tumor metastases and limited treatment options, RFA provides effective local control with prompt symptomatic improvement.

Pattern of calcium and parathyroid hormone normalization at 12-months follow-up after parathyroid operation.

BACKGROUND: At 12 months after a parathyroid operation, we expect cured patients to have biochemical profiles similar to those of healthy individuals. The aim of the current study was to compare the biochemical characteristics patients at 12 months after parathyroidectomy for primary sporadic hyperparathyroidism with those of healthy controls. METHODS: A total of 547 patients who underwent parathyroid neck operation for primary sporadic hyperparathyroidism from 2000-2014 were analyzed. A control group consisted of 74 healthy subjects. Calcium and parathyroid hormone were collected perioperatively. Graphic plots of the relationship between calcium versus parathyroid hormone (95% confidence intervals) were used to compare the biochemical profiles of patients after parathyroid operation and controls. RESULTS: Preoperatively, patients with primary sporadic hyperparathyroidism had a calcium level of 10.9 ± 0.5 mg/dL and parathyroid hormone level of 124.4 ± 68.5 pg/dL vs controls' values of 9.2 ± 0.3 mg/dL and 34.4 ± 13.4 pg/dL, respectively. Before operation, all primary sporadic hyperparathyroidism patients had calcium versus parathyroid hormone values outside the normal zone. At 12 months after operation, 335 (69%) patients showed normalization of the chemical profile; 13 (2.7%) had absolute elevation of calcium and parathyroid hormone, reflecting persistent disease; 2 (0.4%) patients had hypoparathyroidism after subtotal parathyroidectomy; and 149 (31%) had calcium and parathyroid hormone values outside the normal zone, not fitting into the above categories. There were no marked differences between patients with simple adenoma those with multiple-gland disease. CONCLUSION: Longer follow-up might be needed for patients after parathyroid operation to confirm stabilization of biochemical profiles.

Predictors of survival after radiofrequency thermal ablation of colorectal cancer metastases to the liver: a prospective study.

PURPOSE: The aim of this study was to determine the predictors of survival at the time of radiofrequency thermal ablation (RFA) in patients with colorectal liver metastasis. PATIENTS AND METHODS: One hundred thirty-five patients with colorectal liver metastases who were not candidates for resection underwent laparoscopic RFA. RESULTS: The median Kaplan-Meier survival for all patients was 28.9 months after RFA treatment. Patients with a carcinoembryonic antigen (CEA) less than 200 ng/mL had improved survival compared with those with a CEA more than 200 (34 v 16 months; P = .01). Patients with the dominant lesion less than 3 cm in diameter had a median survival of 38 v 34 months for lesions 3 to 5 cm, and 21 months for lesions greater than 5 cm (P = .03). Survival approached significance for patients with one to three tumors versus more than three tumors (29 v 22 months; P = .09). The presence of extrahepatic disease did not affect survival. Only the largest liver tumor size more than 5 cm was found to be a significant predictor of mortality by Cox proportional hazards model, with a 2.5-fold increased risk of death versus the largest liver tumor size less than 3 cm (P = .05). CONCLUSION: This study determines which patients do best after RFA. Historical survival with chemotherapy alone is 11 to 14 months, suggesting RFA has a positive impact on overall survival. Limited amounts of extrahepatic disease do not appear to affect survival adversely. RFA is a useful adjunct to chemotherapy in those patients with liver-predominant disease.

Use of surgeon-performed office ultrasound and parathyroid fine needle aspiration for complex parathyroid localization.

BACKGROUND: This study investigates the utility of ultrasound guided parathyroid fine needle aspiration (FNA) as a localizing technique in patients with hyperparathyroidism (HPT) undergoing re-operative neck surgery or with unusually appearing or ectopically located glands. METHODS: Selected patients with HPT underwent surgeon-performed FNA with ultrasound guidance. Aspirate contents were sent for cytology and parathyroid hormone (PTH) levels. All patients subsequently underwent parathyroid exploration. RESULTS: 54 patients underwent 57 ultrasound guided parathyroid biopsies. Indications for FNA included prior parathyroid (n = 29), thyroid (n = 11), or other neck surgery (n = 2), or unusual parathyroid appearance or location (n = 12). A true positive was defined as a site where the PTH aspirate was >40 pg/mL and a hypercellular gland was removed at surgery. Based on this, there were 44 true positives, 10 true negatives, and 3 false negatives; there were no false positives. The median PTH level in positive aspirates was 11,665 pg/mL. Cytology was primarily helpful in excluding other diagnoses. CONCLUSION: Ultrasound guided FNA is a highly specific localization test for parathyroid tumors. This procedure can be successfully performed by surgeons in the office setting and is extremely valuable for directing parathyroid exploration in challenging cases. We recommend incorporating ultrasound and FNA as a pre-operative localization strategy for selected patients with HPT.

The coming of age of radiation-induced hyperparathyroidism: evolving patterns of thyroid and parathyroid disease after head and neck irradiation.

BACKGROUND: This study investigates the association of thyroid and parathyroid disease in radiation-exposed patients and tests the hypothesis that hyperparathyroidism (HPT) occurs after a longer latency period. METHODS: Routine questioning identified 40 patients in the endocrine surgery clinic with a history of radiation exposure. Patients with thyroid disease were screened for HPT and vice versa. RESULTS: The known diagnosis at initial referral was thyroid disease alone in 26 of 40 patients, HPT alone in 9 of 40 patients, and both in 5 of 40 patients. After screening was completed, a total of 18 of 40 patients were found to have both thyroid disease and HPT. HPT manifested an average of 17 years later than thyroid disease (52.6 +/- 10.0 years vs 35.5 +/- 13.8 years after radiation therapy [ P < .05]). One third of the patients with HPT had normal serum calcium levels despite elevated parathyroid hormone levels and abnormal parathyroid glands. CONCLUSION: As the widespread use of x-ray therapy for benign childhood conditions becomes more remote, practitioners should expect a decreasing number of patients with radiation-associated thyroid disease, with an increase in HPT. Patients with radiation exposure and thyroid disease should be evaluated carefully and followed for HPT. Those patients who undergo surgical procedures should have close inspection of the parathyroid glands, with biopsy and excision when appropriate.

The use of the harmonic scalpel vs conventional knot tying for vessel ligation in thyroid surgery.

HYPOTHESIS: The technique of thyroidectomy has undergone little change in several decades. The harmonic scalpel, using ultrasonic frictional heating to ligate vessels, is widely used in laparoscopic surgery, but there is little experience in open thyroidectomy. We hypothesized that the use of the harmonic scalpel could lead to a significant reduction in operative time as compared with knot tying in thyroid surgery. DESIGN: Retrospective case-controlled study. SETTING: Teaching institution. PATIENTS: One hundred seventy-one consecutive patients undergoing lobectomy or total thyroidectomy by one surgeon (A.E.S.). INTERVENTIONS: Eighty-six patients underwent thyroid surgery with the conventional clamp-and-tie technique (lobectomy, n = 49; total thyroidectomy, n = 36) and 85 with the harmonic scalpel (lobectomy, n = 38; total thyroidectomy, n = 47). MAIN OUTCOME MEASURES: Demographics, pathological characteristics, thyroid size, operative time, blood loss, and complications using a 2-tailed t test, chi(2)test, and Wilcoxon rank sum test. RESULTS: The 2 groups were similar regarding age and sex. There were no intraoperative complications. Mean +/- SD thyroid size tended to be larger in the harmonic scalpel group for both lobectomy (5.1 +/- 2.6 cm vs 4.2 +/- 2.2 cm; P =.06) and total thyroidectomy specimens (6.3 +/- 3.8 cm vs 4.8 +/- 2.9 cm; P =.08) compared with the conventional technique. Mean +/- SD operative time was shorter in the harmonic scalpel group compared with the conventional technique group for both lobectomy (89 +/- 20 minutes vs 115 +/- 25 minutes; P<.01) and total thyroidectomy (132 +/- 39 minutes vs 161 +/- 42 minutes; P<.01) procedures. There was no difference between the 2 techniques regarding the amount of blood loss for different procedures. There was no effect of tumor size on operative time (Pearson correlation factors: 0.14 for total, 0.21 for unilateral thyroidectomy). CONCLUSIONS: The use of the harmonic scalpel for the control of thyroid vessels during thyroid surgery is safe, and it shortens the operative time by almost 30 minutes compared with the conventional technique for both unilateral lobectomy or total thyroidectomy procedures.

Results of laparoscopic adrenalectomy for suspected and unsuspected malignant adrenal neoplasms.

BACKGROUND: Laparoscopic resection for malignant adrenal tumors is controversial, because they are rare and limited data exist in the literature. HYPOTHESIS: Laparoscopic adrenalectomy for malignant adrenal tumors is safe and effective. PATIENTS AND METHODS: Twenty-three patients who had a laparoscopic approach for suspected and unsuspected malignant adrenal tumors were studied retrospectively. The adrenal mass was suspected to be metastatic if the patient had a history of previous extra-adrenal primary malignancy and/or positive fine-needle aspiration cytologic findings. A primary adrenal cancer was suspected if there were positive fine-needle aspiration cytologic findings and/or a malignant adrenal imaging phenotype. MAIN OUTCOME MEASURES: (1) Margins of tumor resection, (2) tumor recurrence (locoregional, port site, and distant), and (3) disease-free survival. RESULTS: Twenty-three patients (15 men and 8 women) had 24 laparoscopic procedures (20 adrenalectomies, 3 biopsies, and 1 diagnostic laparoscopy). Permanent histologic specimens in the 23 patients showed 5 adrenocortical cancers, 1 undifferentiated adrenal cancer, 13 adrenal metastases, 2 lymphomas, and 2 cases with no evidence of tumor. Clinically suspected adrenal metastases were true positive in 19 patients (83%). The sensitivity of fine-needle aspiration cytology was 57% (n = 7). Only 1 of 6 patients with primary adrenal cancer was suspected to have a malignant tumor preoperatively. The tumor resection margin was negative in all adrenalectomies. There were 3 locoregional recurrences (2 local and 1 lymph node metastasis) in the 6 patients with primary adrenal cancer, no port site recurrences, and 4 distant recurrences in 13 patients with metastatic adrenal tumors. The disease-free survival was 65% at a mean follow-up time of 3.3 years (range, 1-7 years). CONCLUSIONS: A laparoscopic approach in patients with suspected adrenal metastasis can be both diagnostic and therapeutic, and achieves complete tumor resection. In contrast, laparoscopic adrenalectomy for clinically unsuspected adrenocortical cancer is associated with a high recurrence rate. Furthermore, preoperative fine-needle aspiration cytology for the evaluation of suspected malignant adrenal tumors is unreliable.

Laparoscopic ultrasonography and biopsy of hepatic tumors in 310 patients.

BACKGROUND: Laparoscopic ultrasonography is increasingly being recognized as an important tool in the evaluation of patients with possible hepatic tumors. The aim of this paper is to describe the technical aspects of imaging and biopsy based on our experience in 310 patients with 1,080 primary and metastatic liver tumors within a 6.5-year period. METHODS: A 10-mm rigid or flexible, 7.5 MHz linear, side-viewing laparoscopic ultrasonography probe was used for imaging, and an 18G spring-loaded core biopsy gun was used for tissue diagnosis. RESULTS: There were no complications. The entire liver was imaged using a right subcostal port. Using a free-hand technique, the needle was best targeted into the lesion when inserted parallel to the plane of the transducer. The rigid transducer was found to be more convenient to guide needle placement. CONCLUSIONS: The use of this minimally invasive technique avoids laparotomy in many patients undergoing staging of malignancy and also offers increased sensitivity for tumor detection compared with conventional imaging modalities.

Laparoscopic ultrasound.

Laparoscopic ultrasonography is a relative latecomer to the area of surgical sonography whose arrival can be attributed to the need for development of specialized transducers that could fit through conventional laparoscopic trocars. The quality, reliability, and ease of use of such units has evolved rapidly, so that laparoscopic ultrasonography may now be performed on a routine basis. Laparoscopic ultrasonography allows the surgeon to look into the tissues being operated upon, thereby compensating for the inability to physically palpate such tissues. Thus, it has not only helped to mimic open surgery, but has also refined the current techniques of laparoscopic operations. With the increasing availability of equipment, as well as the training of surgeons in this modality, laparoscopic ultrasound is quickly becoming an essential tool for the surgeon aiming to take laparoscopic surgery to new frontiers.