Calcium phosphate deposition, tertiary hyperparathyroidism, and the long-term effect on kidney allografts.

BACKGROUND: Tertiary hyperparathyroidism adversely affects kidney allografts, with calcium phosphate deposition hypothesized to be an underlying cause. We analyzed allograft biopsies to investigate risk factors for calcium phosphate deposition and understand its impact on allograft function. METHODS: We reviewed patients who underwent kidney transplantation from 2017 to 2019. Tertiary hyperparathyroidism was defined as an elevated parathyroid hormone and hypercalcemia beyond 3 months' posttransplant or being prescribed cinacalcet. Allograft failure was defined as needing dialysis posttransplantation or retransplantation beyond 3 months' posttransplant. Three- and 12-month allograft biopsies were reviewed for calcium phosphate deposition. The χ2, t-test, and multivariate regression were used for statistical analysis. RESULTS: Of 159 patients who underwent kidney transplantation, 59 (37.1%) were diagnosed with tertiary hyperparathyroidism. Longer preoperative dialysis vintage (odds ratio, 1.47; confidence interval, 1.22-1.80 P < .001) and preoperative cinacalcet usage (odds ratio, 18.4; confidence interval, 7.24-53.0 P < .001) were associated with tertiary hyperparathyroidism. In total, 36 of 59 (61%) patients with tertiary hyperparathyroidism had calcium phosphate deposition on 3- or 12-month kidney allograft biopsy compared with 23 of 100 (23%) patients without tertiary hyperparathyroidism (P < .001). Tertiary hyperparathyroidism (odds ratio, 6.01; confidence interval, 2.91-13.0 P < .001) was associated with calcium phosphate deposition. Calcium phosphate deposition and tertiary hyperparathyroidism were not associated with worse glomerular filtration rate at 3 years' posttransplantation. Of those with data available at 3 years' posttransplantation, 21 of 49 (42.9%) patients remained on cinacalcet. There were 3 of 159 (2%) patients who had allograft failure, 2 of whom had both tertiary hyperparathyroidism and calcium phosphate deposition. CONCLUSION: Preoperative variables associated with tertiary hyperparathyroidism included longer dialysis vintage and cinacalcet use. Tertiary hyperparathyroidism was the main risk factor for calcium phosphate deposition posttransplantation. In our population, calcium phosphate deposition and tertiary hyperparathyroidism were not significantly associated with lower glomerular filtration rate.

Use of PSMA PET/CT to detect prostate cancer metastatic to a preexisting thyroid nodule.

Prostate cancer (PCa) seldom metastasizes to the thyroid gland, and only a limited number of cases are documented in the literature. The application of a relatively recent and highly sensitive imaging technique, prostate-specific membrane antigen (PSMA) positron emission tomography-computed tomography (PET/CT), has enhanced the identification of metastatic disease. Nevertheless, as PSMA is expressed in various tissue types, the clinical importance of a PSMA-avid thyroid lesion remains largely uncertain. A minor, yet noteworthy, percentage of these lesions are ultimately determined to be malignant. Here we describe the case of a 70-year-old man with a past medical history of Lynch syndrome who presented to an outpatient oncologic clinic for management of very high risk localized PCa. He developed metastatic recurrence and his disease progressed through several lines of therapy, including immunotherapy and targeted treatments. He was found to have a new, intense PSMA uptake in an existing, previously benign thyroid nodule. Sonographic evaluation revealed changing morphology despite grossly stable size. Repeat biopsy confirmed the unusual finding of PCa metastasis to a known thyroid nodule. The shift in PSMA avidity played a pivotal role in discerning this metastatic deposit. There is a potential risk that such lesions may be inadequately acknowledged. The impact of the patient's Lynch syndrome on this presentation remains uncertain.

Thyroid Nodule Radiofrequency Ablation: Complications and Clinical Follow Up.

Radiofrequency ablation (RFA) is an increasingly popular non-surgical alternative for the treatment of benign thyroid nodules. Although RFA is less invasive than surgery, it is not without its own risks with major complications occurring at a rate ranging up to 3.8% in large systematic reviews. We review the range of minor and major complications that have been described after thyroid RFA and their potential management. We also review recommended post-ablation follow-up schedules as well as expectations on thyroid nodule volume rate reduction after treatment. Long term follow-up is necessary as there can be regrowth of ablated thyroid nodules due to an undertreated nodule margin. Overall, RFA has been shown to be a consistently safe and effective treatment for thyroid nodules with excellent long-term results.

Association of a Multimodal Intervention With Decreased Opioid Prescribing After Neck Dissection for Malignant Thyroid Disease With Short Hospital Stay.

Importance: Prescribing practices for opioid medication after thyroid surgery have been well-studied and established; however, the need for pain management with opioid medication following lateral neck dissection for malignant thyroid disease with a short hospital stay has not been established. Objective: To evaluate a multimodal opioid reduction intervention and its association with a decrease in prescribing of opioid medication at hospital discharge for patients after a lateral neck dissection for thyroid cancer. Design, Setting, and Participants: This was a retrospective cohort study of patients treated from 2011 to 2021 by a tertiary academic institution that performs a high volume of thyroid cancer surgeries annually. We evaluated the electronic health records of 417 patients who had undergone lateral neck dissection for malignant thyroid disease from June 1, 2011, to June 30, 2021, and had a short hospital stay (≤3 days). Patients with longer stays (>3 days) or additional surgical procedures were excluded. Group 1 comprised patients who underwent a neck dissection before the intervention; and group 2, those who underwent the procedure after implementation of the intervention. Intervention: A multimodal intervention composed of 3 components to reduce opioid prescribing at hospital discharge home after neck dissection for malignant thyroid disease with a short hospital stay. Main Outcomes and Measures: The primary outcome was the quantity of opioid medication prescribed in the postoperative period, measured as oral morphine milliequivalents (MME). The eta-squared effect size (η2ES) metric was used to determine the association of the intervention with a reduction in the MME quantities of opioid medication administered to inpatients and prescribed at discharge. An estimated need for opioids was established for the average patient undergoing lateral neck dissection for thyroid cancer based on the upper range of prescribing after intervention. The data were analyzed from January to March 2022. Results: The total study population was 417 patients: group 1 with 171 patients (mean [SD] age , 47.1 [15.6] years; 104 [61%] women; 144 [84%] non-Hispanic White) and group 2 with 246 patients (mean [SD] age , 46.2 [17.4] years; 146 [60%] women; 206 [83.7%] non-Hispanic White). The median MME prescribed at discharge for group 1 per patient was 225 MME compared with 0 MME for group 2, a large effect-size difference. There was a moderate association between the dose amount administered to an inpatient and the prescription dose they received at discharge (r, 0.33). Multiple linear regression analysis of sex, age, race and ethnicity, extent of surgery, and opioid reduction intervention showed that the intervention had a large clinically meaningful association with decreasing opioid prescriptions and dosage amounts at discharge (η2ES, 0.26; 95% CI, 0.19-0.33). Conclusions and Relevance: The findings of this retrospective cohort study suggest that patients undergoing lateral neck dissections for thyroid cancer with short hospitalization needed very small amounts, if any, postoperative opioid medication for pain management. Adequate postoperative pain control was achieved using nonopioid interventions. Implementing an intervention to decrease the quantity of unnecessarily prescribed opioid medications during hospital discharge may help to reduce the risk of opioid addiction and overdose in patients after surgery.

Clinical Features, Management, and Molecular Characteristics of Familial Small Bowel Neuroendocrine Tumors.

Small bowel neuroendocrine tumors are rare tumors with an increasing incidence over the last several decades. Early detection remains challenging because patients commonly develop symptoms late in the disease course, often after the tumors have metastasized. Although these tumors were thought to arise from sporadic genetic mutations, large epidemiological studies strongly support genetic predisposition and increased risk of disease in affected families. Recent studies of familial small bowel neuroendocrine tumors have identified several novel genetic mutations. Screening for familial small bowel neuroendocrine tumors can lead to earlier diagnosis and improved patient outcomes. This review aims to summarize the current knowledge of molecular changes seen in familial small bowel neuroendocrine tumors, identify clinical features specific to familial disease, and provide strategies for screening and treatment.

Laparoscopic resection of gastrointestinal stromal tumors: Does laparoscopic surgery provide an adequate oncologic resection?

Gastrointestinal stromal tumors (GISTs) are rare tumors of the GI tract. Surgical resection remains the mainstay of non-metastatic disease. However, the ability to provide an adequate oncologic resection using laparoscopic surgery is still an area of debate. This is a thorough review of the current literature, looking particularly at the use of laparoscopic surgery for larger GISTs and the long-term oncologic outcomes compared to the results of open surgery. Laparoscopic resections provide an adequate oncologic result for GISTs of all sizes, including those greater than 5 cm in size.

Differences in single gland and multigland disease are seen in low biochemical profile primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism is characterized by increased levels of serum calcium and parathyroid hormone. Recently, 2 additional mild biochemical profiles have emerged, normocalcemic and normohormonal primary hyperparathyroidism. We reviewed our surgical experience of mild biochemical profile patients and compared them with classic primary hyperparathyroidism patients. METHODS: This is a single institution, retrospective cohort review of all patients who underwent parathyroidectomy for primary hyperparathyroidism from 2006-2012. Preoperative and intraoperative variables were analyzed. Univariable analysis was performed with analysis of variance and the χ2 test. A logistic regression was performed to identify significantly independent predictor variables for multigland disease. RESULTS: A total of 573 patients underwent parathyroidectomy for primary hyperparathyroidism (classic, n = 405; normohormonal, n = 96; normocalcemic, n = 72). Normocalcemic primary hyperparathyroidism was associated with multigland disease in 43 (45%, P < .001) patients as compared with the normohormonal (7, 10%) and classic (36, 9%) groups. On logistic regression, significant predictors for multigland disease were the normocalcemic subtype and positive family history. Twelve month biochemical normalization rates after operative treatment were >98% in all 3 groups. CONCLUSION: Our series shows that normocalcemic primary hyperparathyroidism is associated with a high incidence of multigland disease. Normohormonal disease is similar to classic disease patients with >90% presenting with single adenomas. Excellent rates of biochemical normalization can be obtained by operative treatment in all 3 groups.

Laparoscopic surgery in the management of Crohn's disease.

Crohn's disease is a chronic inflammatory bowel disease with surgery still frequently necessary in its treatment. Since the 1990's, laparoscopic surgery has become increasingly common for primary resections in patients with Crohn's disease and has now become the standard of care. Studies have shown no difference in recurrence rates when compared to open surgery and benefits include shorter hospital stay, lower rates of wound infection and decreased time to bowel function. This review highlights studies comparing the laparoscopic approach to the open approach in specific situations, including cases of complicated Crohn's disease.