Tumour size predicts risk of recurrence in tall cell subtype papillary thyroid carcinoma.

BACKGROUND: The tall cell subtype of papillary thyroid cancer (TCPTC) is the most common aggressive subtype and often treated aggressively. This approach may not be necessary in smaller tumours without adverse histological characteristics. METHODS: 97 patients with TCPTC defined as a height-to-width ratio of ≥3:1 and at least 30% tall cells were compared against 390 classical papillary thyroid carcinoma (CPTC) based on tumour size with recurrence free survival (RFS) as the primary outcome. RESULTS: TCPTC are more likely to present with adverse histological characteristics. In smaller tumours (<2 â€‹cm), only central lymph node metastasis (HR7.16 p â€‹= â€‹0.03) and multifocality (HR10.11 p â€‹= â€‹0.026) increased recurrence risk. In larger tumours, TCPTC histology (HR3.78 p â€‹= â€‹0.002), lymphovascular invasion (HR3.02 p â€‹= â€‹0.014) and central lymph node metastasis (HR3.24 p â€‹< â€‹0.001) significantly increased recurrence risk. CONCLUSION: TCPTC tumours <2 â€‹cm without central lymph node metastasis and multifocality are similar in risk of recurrence to classical PTC and could be managed with lobectomy.

Preoperative ultrasound characteristics in determining the likelihood of requiring completion thyroidectomy for cytologically confirmed (Bethesda VI) papillary thyroid tumors with 1 - 4 cm in diameter.

BACKGROUND: Papillary thyroid carcinoma (PTC) is the most commonly diagnosed differentiated thyroid carcinoma. There is controversy about performing upfront lobectomy vs thyroidectomy for smaller well differentiated thyroid carcinoma. METHODS: A retrospective study from 2015 to 2020 was conducted consisting of consecutive patients with a preoperative malignant (Bethesda VI) cytology on fine needle aspirate (FNA) consistent with PTC. Specific ultrasonographic features such as taller than wide, hypoechogenicity, irregular margins, internal vascularity and microcalcifications were recorded. Criteria for exclusion was the presence of positive lymph nodes, extrathyroidal extension, familial thyroid carcinoma and bilateral disease detected preoperatively. Outcome was defined as a lobectomy being adequate treatment or a completion thyroidectomy recommended based on current 2015 ATA guidelines. RESULTS: Preoperative malignant cytological nodules (Bethesda VI) with irregular margins on sonography were significantly (p = 0.025) at increased risk (OR = 2.48) of requiring a completion thyroidectomy. There was also no statistically significant difference between groups when stratified by size with 50% of tumours between 1 and 2 cm requiring a completion thyroidectomy. CONCLUSIONS: The presence of irregular margins on ultrasound predicts an increased risk of requiring a completion thyroidectomy. Specific consideration of this sonographic finding should be made when counselling patients who have cytologically confirmed papillary thyroid carcinoma regarding the best choice of thyroid operation.

Management of adrenocortical carcinoma in Western Australia: a perspective over 14 years.

BACKGROUND: Adrenocortical carcinoma is a rare but aggressive form of endocrine neoplasm that confers a poor prognosis. To date, the only Australian data published is from New South Wales. This paper describes our experience in Western Australia with a focus on surgical approach and outcomes. METHODS: A retrospective study of patients treated for adrenocortical carcinoma in Western Australia over 14 years was performed. RESULTS: Over the 14-year period, a total of 33 patients underwent surgery for adrenocortical carcinoma. Resection outcomes were superior in an open en bloc approach with an 85% R0 margin (P = 0.007). Local recurrence rates were lowest in an open en bloc approach (11%) compared to laparoscopic (75%). Multivariate analysis showed that an en bloc resection is highly correlated with an R0 resection (P < 0.05) and significantly associated with lower (odds ratio = 0.06) local recurrence (P = 0.009). Higher volume surgeons (>5 cases) had lower operative times and blood loss. Compliance with mitotane was significantly improved with close monitoring of levels. The European Network for the Study of Adrenal Tumours (ENSAT) stage at presentation was most predictive of long-term survival with 100% of stage I patients alive compared to 53% of stage II, 25% of stage III and 17% of stage IV patients at the end of the follow-up period. CONCLUSION: An open en bloc approach with a low threshold for multi-visceral resection performed by high volume surgeons have improved outcomes in local recurrence, operative times and blood loss.

Intraoperative nerve monitoring in endocrine surgery: prevalence and reasons for its use in Australia and New Zealand.

BACKGROUND: Intraoperative nerve monitoring (IONM) has increasingly been used in thyroid surgery by general, endocrine and head and neck surgeons. The purpose of this paper was to explore the prevalence and reasons for the usage of IONM in endocrine surgery in Australia and New Zealand. METHODS: A survey was sent to general surgeons registered with the Royal Australasian College of Surgeons involved in endocrine surgery and members of the Australian and New Zealand Endocrine Surgeons. Users were divided into surgeon type, area of work, hospital type and volume of surgery. These data were analysed with univariate and multivariate logistic regression models. RESULTS: Significant differences in IONM usage levels were observed between endocrine and general surgeons, area of work and volume of surgery performed. Endocrine surgeons are significantly more likely to use IONM than general surgeons. Surgeons who work in tertiary hospitals are more likely to use IONM as compared to those working in district hospitals. Surgeons who perform less than 100 thyroidectomies were more likely to be users of IONM. CONCLUSION: IONM is not routinely used in thyroid surgery in Australia and New Zealand. The main reasons for the use of IONM given in our study by routine users were to establish familiarity of equipment and medicolegal reasons. Selective users chose as the most common reasons, a documented pre-existing unilateral nerve paresis or a hostile surgical field. Non-users stated that there was conflicting evidence that it improves outcomes and increased costs.

Can we predict expected adenoma weight preoperatively with reference to the correlation of preoperative biochemical tests with parathyroid adenoma weight?

BACKGROUND: Primary hyperparathyroidism is a prevalent disease with proven benefits for appropriately selected patients who undergo parathyroidectomy. The ability to accurately predict expected single adenoma gland weight as the cause based on preoperative biochemical tests could improve cure rates in a minimally invasive approach. OBJECTIVE: To assess the correlation between parathyroid weight and preoperative parathyroid hormone and calcium levels in patients with primary hyperparathyroidism with a solitary adenoma and determine if these could be used to predict expected parathyroid weight. METHODS: Patients with primary hyperparathyroidism who underwent curative parathyroidectomy from 2013 to 2018 was retrospectively analysed. RESULTS: There is a strong positive correlation r = 0.602 between preoperative PTH levels with respect to parathyroid weight (p < 0.001). There was a moderate correlation r = 0.474 between preoperative adjusted Calcium and PTH weight (p < 0.001). An algorithm was developed to calculate predicted weight of a single adenoma but when tested against cases with hyperplasia and double adenomas during the period, the variability of predicted weight meant it was impossible to differentiate between the causes. Hyperplasia was excluded and 95% of double adenomas excluded however, when parathyroid weight exceeded 1200 mg CONCLUSION: There is a strong correlation between preoperative PTH levels and calcium levels with parathyroid weight. The large variability of predicted parathyroid weight however, precludes the use of biochemical tests alone preoperatively in being able to differentiate between a single adenoma, double adenoma or hyperplasia as the cause in primary hyperparathyroidism. At parathyroid predicted weights above 1200 mg however, all cases of hyperplasia, and 95% of double adenomas excluded.

A Case Report of Syndromic Multinodular Goitre in Adolescence: Exploring the Phenotype Overlap between Cowden and DICER1 Syndromes.

BACKGROUND: Hereditary tumour predisposition syndromes may increase the risk for development of thyroid nodules at a young age. We present the case of an adolescent female with Cowden syndrome who had some atypical phenotypic features which overlapped with the DICER1 syndrome. MATERIAL AND METHODS: A 17-year-old female presented with a 3-month history of progressive right neck swelling. Fine needle cytology of the thyroid revealed a follicular neoplasm with features suggestive of follicular variant of papillary thyroid carcinoma and she underwent a hemithyroidectomy. Enlarging nodules in the remaining thyroid led to a completion thyroidectomy at 19 years of age. The patient's past medical history included an ovarian mixed malignant germ cell tumour, pulmonary nodules and cysts, renal cysts, mucocutaneous lesions, an arachnoid cyst, and a fibrous breast lesion. Macrocephaly was noted on physical examination. RESULTS: Based on the patient's complex phenotype and young age, a hereditary predisposition syndrome was suspected and genetic testing of PTEN and DICER1 was undertaken. A heterozygous truncating germ-line PTEN mutation was identified, which combined with clinical findings, met criteria for the diagnosis of Cowden syndrome. Additional loss of heterozygosity of the wild-type PTEN allele was detected in the right thyroid lesion and ovarian tumour. No DICER1 mutations were identified. CONCLUSIONS: Genetic testing was crucial in elucidating this patient's predisposition to the early development of neoplastic and non-neoplastic conditions. Our report also highlights the phenotypic overlap between the Cowden and DICER1 syndromes and illustrates the importance of recognising the variable phenotypic features of hereditary syndromes in order to enable timely implementation of appropriate care.

Upstream guppies (Poecilia reticulata, Peters, 1859) go against the flow / Gupies (Poecilia reticulata, Peters, 1859) de áreas de cabeceira se posicionam contra a corrente

Guppies (Poecilia reticulata Peters 1859) in lakes and from captive-bred populations are predicted to show little rheotaxis compared to conspecifics in a stream environment that are regularly exposed to flash floods associated with involuntary downstream migration. Here we test this hypothesis using an artificial stream, examining guppies of two wild riverine populations, one lake population, and one ornamental strain. Guppies from the most upstream riverine habitat show the most pronounced rheotaxis and are less likely to be swept downstream during flooding events. However, there is no significant difference between guppies from the lowland riverine habitat, the Pitch Lake and ornamental strain. We propose that station-keeping behaviours are most strongly selected in the upstream population because large spatial differences exist in ecology and environment between up- and downstream habitats. Given that these sites are separated by barrier waterfalls that prevent compensatory upstream migration, natural selection operates particularly strong against upstream guppies that have been displaced downstream during flooding events.

Populações de guppies (Poecilia reticulata Peters) que vivem em lagos e em cativeiro podem demonstrar menos reotaxia em comparação com populações que habitam rios e que estão frequentemente expostas a enchentes e que provocam a migração involuntária para jusante. Neste trabalho, vamos testar esta hipótese num rio artificial utilizando guppies de duas populações selvagens que habitam em rios, uma população que habita em lagos, e uma linhagem ornamental. Os resultados demonstram que os guppies de rios que provêm de localidades a montante demonstram maior reotaxia, diminuindo assim probabilidade de serem arrastados para jusante em períodos de enchentes. No entanto, não foram encontradas diferenças significativas entre guppies de localidades a jusante, do lago Pitch ou ornamentais. Este resultado pode dever-se ao facto de existirem grandes diferenças ecológicas entre os habitats localizados a jusante e a montante dos rios. Devido ao facto de estas localidades estarem separadas por cachoeiras, impossibilitando a migração rio-acima, a seleção natural poderá estar a actuar contra guppies que sejam arrastados rio abaixo durantes os períodos de cheias.

Differences between endocrinologists and endocrine surgeons in management of the solitary thyroid nodule.

BACKGROUND: It is not known whether management of the solitary thyroid nodule differs between endocrinologists and endocrine surgeons. METHODS: A questionnaire containing a hypothetical case (a 42-year-old euthyroid woman with a 2-x-3-cm solitary thyroid nodule) and 13 clinical variations was sent to endocrinologists and endocrine surgeons in Australia. RESULTS: The response rate was 51%, including 122 endocrinologists and 48 endocrine surgeons. For the index case, serum thyroid-stimulating hormone (TSH), fine needle aspiration biopsy (FNAB) and ultrasonography were widely used by both groups, but thyroid antibody tests and scintigraphy were ordered more commonly by endocrinologists. In the setting of benign cytology, treatment differed significantly between specialties for the index case (endocrinologists: no treatment 78%, surgery 11%, thyroxine 11%; surgeons: no treatment 73%, surgery 25%, thyroxine 2%; P = 0.032). Treatment recommendations also differed significantly for 12 of the 13 clinical variations. In particular, for a patient with a suppressed serum TSH concentration, a majority of endocrinologists recommended radioiodine treatment, whereas surgeons favoured surgery (endocrinologists: radioiodine 53%, surgery 22%, no treatment 25%; surgeons: surgery 60%, radioiodine 11%, no treatment 27%; P < 0.001). For most of the variations, a higher proportion of surgeons than endocrinologists recommended surgical treatment. Comparison with previous surveys of European Thyroid Association and American Thyroid Association members (predominantly endocrinologists) demonstrated considerable international differences in management. CONCLUSION: There are clinically significant differences between Australian endocrinologists and endocrine surgeons in management of the solitary thyroid nodule, and international differences in management of this disorder.

Concomitant compostite adrenal phoechromocytoma, multipte gastric stromal tumours and pseudohermaphrodism in a patient with von Recklinghausen's disease.

Although pheochromocytoma occurs in 1% of patients with von Recklinghausen's disease, composite tumors in this syndrome are much rarer, with isolated case reports in the literature. Most gastrointestinal stromal tumors (GISTs) are solitary and sporadic. Multiple GISTs however, are associated with clinical syndromes particularly von Recklinghausen's disease. We believe this is the first report of composite adrenal pheochromocytoma and multiple GISTs occurring in an 82 year old woman with neurofibromatosis type 1 (NF1), manifested by clitoral and subcutaneous neurofibromas, epilepsy and Lisch nodules. The extreme clitoromegaly raised concerns of pseudohermaphrodism at presentation.