Parathyroidectomy for Tertiary Hyperparathyroidism: A Multi-Institutional Analysis of Outcomes.

BACKGROUND: Patients with tertiary hyperparathyroidism (HPT) often experience delays between diagnosis and referral for surgical treatment. We hypothesized that patients with tertiary HPT experience similarly high cure rates and low complication rates after parathyroidectomy compared with patients with primary HPT. METHODS: We retrospectively identified patients undergoing parathyroidectomy from the Collaborative Endocrine Surgery Quality Improvement Program for primary or tertiary HPT from January 2014 to April 2019. Patients were categorized according to their primary diagnosis and compared for cure rates and surgical complications. RESULTS: The study included 9030 patients, with 334 (3.7%) being treated for tertiary HPT. Parathyroidectomy provided a high cure rate (93.7%) in patients with tertiary HPT. However, adjusting for age, sex, and prior thyroid or parathyroid surgery, tertiary HPT was associated with a greater chance of persistent disease than was primary HPT (odds ratio: 2.3, 95% confidence interval: 1.3-4.0). Overall, complications were low for patients across both groups. However, patients with tertiary HPT were more likely to present to the emergency department (7.5% versus 3.3%; P < 0.001), be readmitted (5.1% versus 1.1%; P < 0.001), and develop a hematoma (1.5% versus 0.2%; P = 0.002). Both groups of patients shared similarly low rates of other complications, including mortality, vocal cord dysfunction, and surgical site infections (P < 0.5% for all). CONCLUSIONS: Patients undergoing parathyroidectomy for tertiary HPT experience high cure rates and low complication rates. However, tertiary HPT is associated with a greater chance of persistent disease and select complications. Nevertheless, the low rates of persistent disease and complications should not deter early referral for the treatment of tertiary HPT.

Implementation of Opioid-Free Thyroid and Parathyroid Procedures: A Single Center Experience.

BACKGROUND: Initial opioid exposure for most individuals with substance use disorder comes from the healthcare system, and overprescription of opioids in ambulatory operations is common. This report describes an academic medical center's experience implementing opioid-free thyroid and parathyroid operations. MATERIALS AND METHODS: This is a retrospective chart review of patients undergoing a thyroid or parathyroid operation before and after implementation of an opioid-free analgesia protocol. The primary endpoint was new postoperative opioid prescription. Secondary endpoints included prescription characteristics and predictors of new opioid prescription. RESULTS: A total of 515 patients were enrolled in the study: 240 in the control or "pre-intervention" cohort (May through October 2017) and 275 in the intervention or "post" cohort (May through October 2018). Patients in the intervention cohort were significantly less likely to receive an opioid prescription (12.0% versus 59.6%, P < 0.001). When opioids were prescribed, they were used for shorter durations and at lower doses in the intervention cohort. Among the patients prescribed opioids in the intervention cohort (N = 33), the only significant predictor of postoperative opioid use was preoperative opioid use (P = 0.001). CONCLUSIONS: Opioids may not be required after thyroidectomy and parathyroidectomy, especially for opioid-naïve patients. Future research should examine patient satisfaction with opioid-sparing analgesia.

Risk of Recurrence in Differentiated Thyroid Cancer: A Population-Based Comparison of the 7th and 8th Editions of the American Joint Committee on Cancer Staging Systems.

BACKGROUND: Differentiated thyroid cancer (DTC) survival is excellent, making recurrence a more clinically relevant prognosticator. We hypothesized that the new American Joint Committee on Cancer (AJCC) 8th edition improves on the utility of the 7th edition in predicting the risk of recurrence in DTC. METHODS: A population-based retrospective review compared the risk of recurrence in patients with DTC according to the AJCC 7th and 8th editions using the Surveillance, Epidemiology, and End Results-based Kentucky Cancer Registry from 2004 to 2012. RESULTS: A total of 3248 patients with DTC were considered disease-free after treatment. Twenty percent of patients were downstaged from the 7th edition to the 8th edition. Most patients had stage I disease (80% in the 7th edition and 94% in the 8th edition). A total of 110 (3%) patients recurred after a median of 27 months. The risk of recurrence was significantly associated with stage for both editions (p < 0.001). In the 7th edition, there was poor differentiation between lower stages and better differentiation between higher stages (stage II hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.39-2.11; stage III HR 3.72, 95% CI 2.29-6.07; stage IV HR 11.66, 95% CI 7.10-19.15; all compared with stage I). The 8th edition better differentiated lower stages (stage II HR 4.06, 95% CI 2.38-6.93; stage III HR 13.07, 95% CI 5.30-32.22; stage IV 11.88, 95% CI 3.76-37.59; all compared with stage I). CONCLUSIONS: The AJCC 8th edition better differentiates the risk of DTC recurrence for early stages of disease compared with the 7th edition. However, limitations remain, emphasizing the importance of adjunctive strategies to estimate the risk of recurrence.

Variation in the Quality of Thyroid Nodule Evaluations Before Surgical Referral.

BACKGROUND: Thyroid nodules are highly prevalent, and owing to their malignant potential, proper evaluation is imperative. The objective of this study was to characterize variation in thyroid nodule evaluations. MATERIALS AND METHODS: This retrospective review included all consecutive surgical referrals for thyroid nodules from October to December 2017 at a single institution. We determined the proportion of evaluations that contained a thyroid-stimulating hormone (TSH) level and a high-quality ultrasound because these components of thyroid nodule evaluations are common to several evidence-based guidelines. RESULTS: The study cohort included 64 patients, with a median age of 51.5 y. Primary care providers referred most patients (51.6%), followed by endocrinologists (40.6%), and other specialists (7.8%). In total, 35.9% of evaluations did not include a TSH value, which is vital to any thyroid nodule evaluation. Most evaluations (95.3%) included a dedicated ultrasound, but only 12.3% of ultrasound reports commented on nodule size in three dimensions, structure, echogenicity, and lymph nodes, which we considered the minimum commentary indicative of a high-quality ultrasound. Only 51.5% of evaluations included both a TSH and a thyroid ultrasound. If patients receiving low-quality ultrasound reports were excluded, 9.4% of the entire cohort received a guideline-concordant, high-quality evaluation. CONCLUSIONS: Great variation exists in the quality of thyroid nodule evaluations before surgical referral. Two necessary components of thyroid nodule evaluations that contribute most to the observed deviation from guidelines are obtaining a TSH value and obtaining an ultrasound with enough information to risk stratify the nodule.

Necrotizing Fasciitis of the Breast Requiring Emergent Radical Mastectomy.

Necrotizing fasciitis is a rare, aggressive, soft-tissue infection that results in necrosis of skin, subcutaneous tissue, and fascia. It spreads rapidly and may progress to sepsis, multi-organ failure, and death. Predisposing conditions include diabetes, chronic alcoholism, advanced age, vascular disease, and immunosuppression and many cases are preceded by an injury or invasive procedure. Necrotizing soft-tissue infection of the breast is uncommon, with only a few reported cases in the literature. We present a 53-year-old diabetic woman who presented to the emergency room with several weeks of worsening breast and shoulder pain, swelling, and erythema. Upon formal evaluation by the surgical service, a necrotizing soft-tissue infection was suspected, and the patient was scheduled for emergent, surgical debridement. Because of the aggressive nature and high mortality of this disease, immediate surgical intervention, coupled with antibiotic therapy and physiologic support, is necessary to prevent complications and death.

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.

Esophageal fistula complicating thyroid lobectomy.

Thyroidectomy is associated with low morbidity and mortality. Esophageal perforation following thyroidectomy has been reported only three times previously, with subsequent fistulization occurring in two of these cases. The authors present the first such case report in the English-speaking literature.

Equipping medical students to manage cancer pain: a comparison of three educational methods.

A Cancer Pain Structured Clinical Instruction Module (SCIM), with skills stations incorporating actual cancer patients, has been developed to enhance cancer pain education among our medical students. The Cancer Pain SCIM has not been compared with more traditional cancer pain education, thus the purpose of this study was to assess the effectiveness and durability of three educational methods for teaching cancer pain management to medical students compared with a control group. Four consecutive rotations of 32 third-year medical students participated in one of four cancer pain educational strategies: 1) control group with no formal cancer pain education, 2) CD-ROM self-instruction module on cancer pain, 3) a 2-hour Cancer Pain SCIM plus the CD-ROM information, and 4) Cancer Pain SCIM, plus CD-ROM, plus a structured home-hospice patient visit. The effectiveness of the educational interventions was assessed at 4 months post-instruction using a 4-component Cancer Pain Objective Structured Clinical Examination (OSCE). The main findings of this educational study are that: 1) all three educational groups performed better on the Cancer Pain OSCE at 4 months than the control group (P<0.05); 2) medical students receiving structured education on cancer pain management significantly out-performed students at 4 months compared with control or traditional instructional formats; 3) students receiving the Cancer Pain SCIM plus home visit performed highest on the pain management, physical exam, and communication stations of the OSCE; and 4) the SCIM format of education shows durability as assessed at 4 months post-instruction. The Cancer Pain SCIM has a unique potential to substantially improve the quality of cancer pain education.

Surgeon-driven thyroid interrogation of patients presenting with primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism (pHPT) is an increasingly prevalent disease affecting all age groups. The authors sought to determine the impact of a "thyroid interrogation" practice protocol on the surgical treatment of patients with the diagnosis of pHPT referred to a single surgeon. STUDY DESIGN: We performed a retrospective review of prospectively gathered data on parathyroidectomy (PTX) patients undergoing both a prospective clinical thyroid evaluation and thyroid ultrasound between January 2008 and October 2012. RESULTS: Only 5.6% of 468 PTX patients were referred to a single surgeon for both parathyroid and thyroid surgical evaluation; 31% of patients had known pre-existing thyroid disease (hypothyroidism most commonly), and 22% of patients had palpable thyroid abnormalities unrecognized in 67% of cases by the referring physician. Of the 468 patients, 2.6% had a history of classic head and neck radiation exposure, 2.6% a history of radio-iodine treatment, and 3% a family history of thyroid cancer. Thyroid abnormalities were found on ultrasound in 61% of patients, and 26% of patients underwent thyroid biopsies. Parathyroid and thyroid surgery was combined for 18.4% of patients; indications included obstructive symptoms (3.2%), hyperthyroidism (0.9%), intraoperative findings (5.1%), and concern for malignancy (9.2%). Malignancy was diagnosed in 23 patients (4.9%), only 8 of whom had been referred for thyroid evaluation. CONCLUSIONS: The majority of patients referred for PTX had evidence of thyroid pathology. For an important minority of these patients, benign and malignant disease was identified that merited surgical treatment at the time of PTX. We recommend comprehensive thyroid evaluation of patients referred for PTX.

Preoperative laryngoscopy in thyroid surgery: Do patients' subjective voice complaints matter?

BACKGROUND: Although routine preoperative laryngoscopy has been standard practice for many thyroid surgeons, there is recent literature that supports selective laryngoscopy. We hypothesize that patients' preoperative voice complaints do not correlate well with abnormalities seen on preoperative laryngoscopy. METHODS: A retrospective chart review of a 3-year, single-surgeon experience was performed. Records of patients undergoing thyroid surgery were reviewed for patient voice complaints, prior neck surgery, surgeon-documented voice quality, and results of laryngoscopy. RESULTS: Of 464 patients, 6% had abnormal laryngoscopy findings, including 11 cord paralyses (2%). Preoperatively, 39% of patients had voice complaints, but only 10% had a corresponding abnormality on laryngoscopy. Only 4% of patients had a surgeon-documented voice abnormality with 72% corresponding abnormalities on laryngoscopy, including 8 cord paralyses. When eliminating patient voice complaints and using only history of prior neck surgery and surgeon-documented voice abnormality as criteria for preoperative laryngoscopy, only 1 cord paralysis is missed and sensitivity (91%) and specificity (86%) were high. Also, when compared with routine laryngoscopy, 84% fewer laryngoscopies are performed. CONCLUSION: When using patients' voice complaints as criteria for preoperative laryngoscopy, the yield is low. We recommend using surgeon-documented voice abnormalities and history of prior neck surgery as criteria for preoperative laryngoscopy.

Intrapericardial parathyroid adenoma†.

Primary hyperparathyroidism from a parathyroid adenoma is common. Ectopic parathyroid glands have been reported in numerous locations, including the chest. We present a single case report of an intrapericardial parathyroid gland found after failed bilateral neck exploration. The patient presented with severe, recurrent nephrolithiasis and acute renal failure prior to his surgical intervention. Repeat imaging identified a parathyroid adenoma in the mediastinum that was localized to the aortopulmonary window. After attempts at minimally invasive thoracotomy and posterolateral thoracotomy, a median sternotomy was ultimately required to identify the adenoma.

Disparity between tissue and serum calcitonin and carcinoembryonic antigen in a patient with medullary thyroid carcinoma.

Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor of parafollicular or C-cells of thyroid that comprises 5-10% of all thyroid cancers [1, 2]. The neoplastic cells secrete calcitonin, carcinoembryonic antigen (CEA), and chromogranin A. Typically, increased serum levels of these tumor markers permit them to be used for initial diagnosis and long-term disease status surveillance. This article reports a case of sporadic MTC (pT2N0M0) in a young patient with normal serum tumor markers. A 16-year-old woman presented with MTC without evidence for this to be a familial case due to the absence of germline mutations in the RET proto-oncogene and negative family history. Surprisingly, there were normal preoperative serum levels of calcitonin, CEA, and chromogranin A, despite the immunohistochemistry showing strong and diffuse positive staining for these markers. This disparity between serum levels and tumor expression of calcitonin and CEA in MTC is quite rare. The relevant features of this case are discussed in consideration of the published experiences. This case may represent an unique subgroup of MTC with abnormal secretory capacity that requires reliance upon radiological evaluation for evidence of recurrent or disseminated disease, without the diagnostic benefit of serum tumor markers.

Cancer pain education for medical students: the development of a short course on CD-ROM.

OBJECTIVE: The purpose of this study was to assess the educational value and acceptability of a short CD-ROM course on cancer pain management given to third-year medical students at the University of Kentucky. METHODS: Thirty-six medical students were given a short-course CD-ROM on cancer pain assessment and management. The Cancer Pain CD-ROM included textual instruction as well as video clips and a 15-item interactive self-assessment examination on cancer pain management. Students were asked to evaluate the computerized course with an 18-item survey using a Likert scale (1 = strongly disagree; 5 = strongly agree). RESULTS: Twenty-seven medical students completed the course, however, only 11 returned evaluations. In general, the medical students appreciated the CD-ROM material, with the exception of the video clips. Students agreed most strongly (mean +/- standard deviation [SD]) that the educational material on the CD-ROM was presented clearly (3.9 +/- 1.1), the CD-ROM format was easy to use (4.0 +/- 0.8), the CD-ROM course improved knowledge of opioid use for cancer pain (4.0 +/- 0.7), and the course improved understanding of opioid-related side effects (4.0 +/- 0.7). The self-assessment examination on cancer pain was rated easy to use and felt to be helpful (4.0 +/- 0.9) for students to identify cancer pain knowledge deficits. The authors estimate that 150 man-hours were needed to complete production of the CD-ROM without any specialized training in computer skills. CONCLUSIONS: A short-course computer format program was developed by the authors to teach the basics of cancer pain management to medical students. A minority of students evaluated the program and agreed the material was clearly presented, improved knowledge of opioid analgesia, and was easy to use.

Enhancing the clinical skills of surgical residents through structured cancer education.

OBJECTIVE: To assess the short and long-term educational value of a highly structured, interactive Breast Cancer Structured Clinical Instruction Module (BCSCIM). SUMMARY BACKGROUND DATA: Cancer education for surgical residents is generally unstructured, particularly when compared with surgical curricula like the Advanced Trauma Life Support (ATLS) course. METHODS: Forty-eight surgical residents were randomly assigned to 1 of 4 groups. Two of the groups received the BCSCIM and 2 served as controls. One of the BCSCIM groups and 1 of the control groups were administered an 11-problem Objective Structured Clinical Examination (OSCE) immediately after the workshop; the other 2 groups were tested with the same OSCE 8 months later. The course was an intensive multidisciplinary, multistation workshop where residents rotated in pairs from station to station interacting with expert faculty members and breast cancer patients. RESULTS: Residents who took the BCSCIM outperformed the residents in the control groups for each of the 7 performance measures at both the immediate and 8-month test times (P < 0.01). Although the residents who took the BCSCIM had higher competence ratings than the residents in the control groups, there was a decline in the faculty ratings of resident competence from the immediate test to the 8-month test (P < 0.004). CONCLUSIONS: This interactive patient-based workshop was associated with objective evidence of educational benefit as determined by a unique method of outcome assessment.