Predicting recurrence of papillary thyroid cancer using the eighth edition of the AJCC/UICC staging system.

BACKGROUND: The AJCC/UICC classification is widely used for predicting survival in papillary thyroid cancer (PTC), but has not been evaluated as a predictor of recurrence. The hypothesis of this study was that the eighth edition of the AJCC system can be used in this novel way. METHODS: All patients in the study underwent surgery for PTC at a high-volume endocrine surgery centre in France between 1985 and 2015. The seventh and eighth editions of the AJCC/UICC staging system for PTC were employed to predict recurrence and disease-specific survival using the Kaplan-Meier and log rank tests. RESULTS: Among 4124 patients (79·7 per cent female), median age was 50 (i.q.r. 38-60) years; 3906 patients (94·7 per cent) underwent total thyroidectomy, with lymph node dissection in 2495 (60·5 per cent). The eighth edition of the AJCC/UICC staging system placed 91·8, 7·1, 0·4 and 0·7 per cent of patients in stages I-IV respectively. After reclassifying patients from the seventh to the eighth AJCC/UICC edition, the disease was downstaged in 23·8 per cent. Over a median follow-up of 7 years, 260 patients (6·4 per cent) developed recurrent disease, including 5·2 per cent of patients with stage I, 19·6 per cent with stage II, 59 per cent with stage III and 50 per cent with stage IV disease, according to the eighth edition. The eighth edition was a better predictor of recurrence than the seventh edition. CONCLUSION: The eighth edition of the AJCC/UICC staging system appears to be a novel tool for predicting PTC recurrence, which is a meaningful outcome for this indolent disease. The eighth edition can be used to risk-stratify patients, keeping in mind that other molecular and pathological predictive factors must be integrated into the assessment of recurrence risk.

Receipt of Care Discordant with Practice Guidelines is Associated with Compromised Overall Survival in Nasopharyngeal Carcinoma.

AIMS: It is unknown whether receiving treatment that is discordant with practice guidelines is associated with improved survival in patients with nasopharyngeal carcinoma. The objectives of this study were to characterise national treatment patterns, analyse whether treatment outside of practice guidelines is associated with overall survival, and identify variables associated with receiving guidelines-discordant care in the USA. MATERIALS AND METHODS: This was a retrospective cohort study of 1741 nasopharyngeal carcinoma patients in the National Cancer Data Base (2003-2006). Treatment regimens were compared with the 2004-2006 National Comprehensive Cancer Network guidelines. Statistical analyses included chi-square, Kaplan-Meier, multivariable logistic, and Cox regression. RESULTS: Nearly 26% of our cohort received care discordant with practice guidelines. In multivariable analysis, patients with stage IVC disease (odds ratio 2.59, 95% confidence interval 1.66-4.04) were more likely to receive guidelines-discordant care when compared with those with stage II-IVB disease. The most common treatment deviation for those with stage I disease was overtreatment with chemoradiation therapy. Receiving guidelines-discordant care was associated with an increased risk of death (hazard ratio 1.46, 95% confidence interval 1.25-1.69). CONCLUSIONS: Many patients with stages I and IVC nasopharyngeal carcinoma do not receive care in accordance with practice guidelines. Receiving guidelines-discordant care is associated with compromised overall survival in the USA.

Patterns of Use and Short-Term Outcomes of Minimally Invasive Surgery for Malignant Pheochromocytoma: A Population-Level Study.

BACKGROUND: Malignant pheochromocytoma is rare, and there is a scarcity of data on the use of minimally invasive surgery (MIS) for treatment. The aims of this study were to analyze patterns of use of MIS for malignant pheochromocytoma in the U.S. and compare short-term outcomes to those of open adrenalectomy. METHODS: Patients with malignant pheochromocytoma undergoing MIS, including laparoscopy, robotic assisted, laparoscopy converted to open, or open adrenalectomy, were culled from the National Cancer Database, from 1998 to 2011. Data were examined using simple summary statistics, Χ2 and student's t tests, Mann-Whitney test, and logistic regression. RESULTS: A total of 36 MIS and 67 open adrenalectomies were identified in 2010-2011. No significant differences were observed between the two treatment groups in demographic characteristics or comorbidities. Preoperative diagnosis of malignancy was made in 52.8% of MIS and 48.5% of open patients (p=NS). MIS and open adrenalectomies did not differ with respect to lymph node metastases, vascular invasion, extra-adrenal-extension, and distant metastases (all p=NS). MIS tended to more often be used to perform partial adrenalectomy (38.9 vs. 20.4% open, p=0.061); surgical margins, 30-day readmission and mortality rates were similar to open adrenalectomy (all p=NS). Tumors removed via MIS were smaller (48.7 vs. 73.3 mm open, p=0.003) and associated with a shorter length of stay. CONCLUSIONS: A significant proportion of patients with malignant pheochromocytomas underwent MIS, with short-term outcomes which are comparable to those of open surgery. Further studies focused on long-term survival and recurrence are needed to assess the role of MIS in the management of these rare tumors.

Radiology reports for incidental thyroid nodules on CT and MRI: high variability across subspecialties.

BACKGROUND AND PURPOSE: Variability in radiologists' reporting styles and recommendations for incidental thyroid nodules can lead to confusion among clinicians and may contribute to inconsistent patient care. Our aim was to describe reporting practices of radiologists for incidental thyroid nodules seen on CT and MR imaging and to determine factors that influence reporting styles. MATERIALS AND METHODS: This is a retrospective study of patients with incidental thyroid nodules reported on CT and MR imaging between January and December 2011, identified by text search for "thyroid nodule" in all CT and MR imaging reports. The studies included CT and MR imaging scans of the neck, spine, and chest. Radiology reports were divided into those that mentioned the incidental thyroid nodules only in the "Findings" section versus those that reported the incidental thyroid nodules in the "Impression" section as well, because this latter reporting style gives more emphasis to the finding. Univariate and multivariate analyses were performed to identify radiologist, patient, and nodule characteristics that influenced reporting styles. RESULTS: Three hundred seventy-five patients met the criterion of having incidental thyroid nodules. One hundred thirty-eight (37%) patients had incidental thyroid nodules reported in the "Impression" section. On multivariate analysis, only radiologists' divisions and nodule size were associated with reporting in "Impression." Chest radiologists and neuroradiologists were more likely to report incidental thyroid nodules in the "Impression" section than their abdominal imaging colleagues, and larger incidental thyroid nodules were more likely to be reported in "Impression" (P ≤ .03). Seventy-three percent of patients with incidental thyroid nodules of ≥20 mm were reported in the "Impression" section, but higher variability in reporting was seen for incidental thyroid nodules measuring 10-14 mm and 15-19 mm, which were reported in "Impression" for 61% and 50% of patients, respectively. CONCLUSIONS: Reporting practices for incidental thyroid nodules detected on CT and MR imaging are predominantly influenced by nodule size and the radiologist's subspecialty. Reporting was highly variable for nodules measuring 10-19 mm; this finding can be partially attributed to different reporting styles among radiology subspecialty divisions. The variability demonstrated in this study further underscores the need to develop CT and MR imaging practice guidelines with the goal of standardizing reporting of incidental thyroid nodules and thereby potentially improving the consistency and quality of patient care.

Imaging-detected incidental thyroid nodules that undergo surgery: a single-center experience over 1 year.

BACKGROUND AND PURPOSE: Incidental thyroid nodules are commonly seen on imaging, and their work-up can ultimately lead to surgery. We describe characteristics and pathology results of imaging-detected incidental thyroid nodules that underwent surgery. MATERIALS AND METHODS: A retrospective review was performed of 303 patients who underwent thyroid surgery over a 1-year period to identify patients who presented with incidental thyroid nodules on imaging. Medical records were reviewed for the types of imaging studies that led to detection, nodule characteristics, and surgical pathology. RESULTS: Of 303 patients, 208 patients (69%) had surgery for thyroid nodules. Forty-seven of 208 patients (23%) had incidental thyroid nodules detected on imaging. The most common technique leading to detection was CT (47%). All patients underwent biopsy before surgery. The cytology results were nondiagnostic (6%), benign (4%), atypia of undetermined significance or follicular neoplasm of undetermined significance (23%), follicular neoplasm or suspicious for follicular neoplasm (19%), suspicious for malignancy (17%), and diagnostic of malignancy (30%). Surgical pathology was benign in 24 of 47 (51%) cases of incidental thyroid nodules. In the 23 incidental cancers, the most common histologic type was papillary (87%), the mean size was 1.4 cm, and nodal metastases were present in 7 of 23 cases (30%). No incidental cancers on imaging had distant metastases. CONCLUSIONS: Imaging-detected incidental thyroid nodules led to nearly one-fourth of surgeries for thyroid nodules, and almost half were initially detected on CT. Despite indeterminate or suspicious cytology results that lead to surgery, more than half were benign on final pathology. Guidelines for work-up of incidental thyroid nodules detected on CT could help reduce unnecessary investigations and surgery.

Prevalence of the polar vessel sign in parathyroid adenomas on the arterial phase of 4D CT.

BACKGROUND AND PURPOSE: The "polar vessel" sign has been previously described on sonography of parathyroid adenomas. We estimated the 4D CT prevalence of the polar vessel sign and determined features of parathyroid adenomas that are associated with this sign. MATERIALS AND METHODS: Twenty-eight consecutive patients with parathyroid adenomas underwent 4D CT between 2008 and 2012 at 2 institutions. 4D CT images were reviewed for the presence of the polar vessel sign and a second vascular finding of an enlarged ipsilateral inferior thyroid artery. The polar vessel sign was correlated with adenoma weight and size and arterial phase CT attenuation. RESULTS: Thirty-two parathyroid adenomas in 28 patients were studied, with a mean adenoma weight of 0.66 ± 0.65 g, a mean maximal CT diameter of 11.1 ± 4.9 mm, and a mean arterial attenuation of 148 ± 47 HU. The polar vessel sign was seen in 20/32 (63%) adenomas. Adenomas with a polar vessel had higher arterial phase attenuation than adenomas without a polar vessel (163 and 122 HU, respectively, P < .01). Size and weight were not significantly different for adenomas with and without polar vessels. An enlarged inferior thyroid artery was seen in only 2/28 (7%) patients with unilateral disease. CONCLUSIONS: The polar vessel sign was present in nearly two-thirds of parathyroid adenomas on 4D CT and was more likely to be present in adenomas that had greater arterial phase enhancement. This sign can be used along with enhancement characteristics to increase the radiologist's confidence that a visualized lesion is a parathyroid adenoma rather than a thyroid nodule or lymph node.

Efficacy and tolerability of pharmacotherapy options for the treatment of medullary thyroid cancer.

Metastatic and unresectable medullary thyroid carcinoma (MTC) is often difficult to treat as it is relatively unresponsive to radiation and conventional chemotherapy. This emphasizes the importance of the development of targeted therapies for advanced MTC. Vandetanib was approved by the US Food and Drug Administration for the treatment of symptomatic or progressive MTC in patients with advanced disease in April 2011. This therapy proved to be a breakthrough in the management of MTC. We review the efficacy and safety of this novel treatment and other treatments that are being evaluated in this disease.

Current management of medullary thyroid cancer.

Medullary thyroid carcinoma (MTC) is an uncommon malignancy of the parafollicular C cells of the thyroid, with a propensity for early lymph node spread and distant metastasis. It is hereditary in approximately 25% of cases, involving specific point mutations of the RET proto-oncogene inherited in an autosomal dominant fashion. While European professional organizations have put forth calcitonin screening guidelines for earlier detection of MTC, the American Thyroid Association, which has published recent guidelines for MTC treatment, have not had a position on routine screening in the USA. Surgical extirpation of the primary tumor and involved lymph node metastases is the mainstay of treatment and the only chance for cure. Conventional systemic chemotherapies for metastatic MTC have been disappointing; however, newer agents which affect specific RET proteins and tyrosine kinase growth factor receptors show promise in phase 1 and 2 clinical trials.

Management of follicular tumors of the thyroid.

The incidence of well-differentiated thyroid cancers is rising. Follicular cancer represents 10-20% of these lesions. While the vast majority of thyroid nodules of follicular origin are benign, fine needle aspiration cannot provide cytologic evidence of capsular and/or vascular invasion; therefore, patients should undergo surgical excision. Frozen section is not recommended for intraoperative evaluation of follicular neoplasia. Patients deemed to have follicular cancer require near-total or total thyroidectomy and postoperative (131)I ablation. The optimal management of minimally invasive follicular cancer remains an area of controversy, but long-term prognosis for these patients is excellent. Areas of research should focus on identification of molecular markers of malignancy and aggressiveness of follicular neoplasia.

Imaging of the adrenal gland.

CT scanning remains the principal imaging technique for delineating adrenal gland lesions. Additional modalities complement CT by providing information about functional status and tissue-specific characteristics of adrenal pathology. They include MR imaging, radionuclide scintigraphy, selective venous sampling, angiography, ultrasound, percutaneous adrenal biopsy, and positive emission tomography.

Cost implications of different surgical management strategies for primary hyperparathyroidism.

BACKGROUND: Controversy exists about optimal management of patients with primary hyperparathyroidism. To date, no studies have explored the cost implications of variation in practice. METHODS: Results from a national survey of endocrine surgeons were combined with results from a survey of endocrinologists and financial data from Medicare. Patterns of use of resources were identified, annual costs for the surgical management of primary hyperparathyroidism in the United States were calculated, and the financial impact of variation in practice was estimated. RESULTS: Survey respondents (n = 109) were experienced endocrine surgeons, performing an average of 33 parathyroidectomies annually. Seventy-five percent of patients undergo localization before initial exploration for primary hyperparathyroidism. In order of preference, these studies were sestamibi (43%), ultrasonography (28%), and sestamibi with single-photon emission computed tomography (26%). Although there is variation in preoperative and postoperative practice, in-hospital costs have the greatest influence on total cost. An estimated $282 million is spent annually in the United States on operations for primary hyperparathyroidism. National health expenditures could range by more than $70 million, depending on whether management strategies involving low or high use of resources are employed. CONCLUSIONS: Substantial variation among endocrine surgeons in the management of primary hyperparathyroidism has important cost implications. Implementation of evidence-based guidelines to optimize clinical and economic performance should be considered.

Should hepatic resections be performed at high-volume referral centers?

Recent studies have demonstrated the relationship between clinical outcomes of complex surgical procedures and provider volume. Hepatic resection is one such high-risk surgical procedure. The aim of this analysis was to determine whether mortality and cost of performing hepatic resection are related to surgical volume while also examining outcomes by extent of resection and diagnosis, variables seen with this procedure. Maryland discharge data were used to study surgical volume, length of stay, charges, and mortality for 606 liver resections performed at all acute-care hospitals between January 1990 and June 1996. One high-volume provider accounted for 43.6% of discharges, averaging 40.6 cases per year. In comparison, the remainder of resections were performed at 35 other hospitals, averaging 1.5 cases per year. Data were stratified into these high- and low-volume groups, and adjusted outcomes were compared. The mortality rate for all procedures in the low-volume group was 7.9% compared to 1.5% for the high-volume provider (P <0.01, relative risk = 5.2). No overall differences were observed between low- and high-volume providers in total hospital charges. When analyzing by procedure type and diagnosis, lower mortality was seen in the high-volume center for both minor and major resections, as well as resections for metastatic disease. It was concluded that hepatic resection can be performed more safely and at comparable cost at high-volume referral centers.

The importance of surgeon experience for clinical and economic outcomes from thyroidectomy.

OBJECTIVE: To determine whether individual surgeon experience is associated with improved short-term clinical and economic outcomes for patients with benign and malignant thyroid disease who underwent thyroid procedures in Maryland between 1991 and 1996. SUMMARY BACKGROUND DATA: There is a prevailing belief that surgeon experience affects patient outcomes in endocrine surgery, but there is a paucity of objective evidence outside of clinical series published by experienced surgeons that supports this view. METHODS: A cross-sectional analysis of all patients who underwent thyroidectomy in Maryland between 1991 and 1996 was conducted using a computerized statewide hospital discharge data base. Surgeons were categorized by volume of thyroidectomies over the 6-year study period: A (1 to 9 cases), B (10 to 29 cases), C (30 to 100 cases), and D (>100 cases). Multivariate regression was used to assess the relation between surgeon caseload and in-hospital complications, length of stay, and total hospital charges, adjusting for case mix and hospital volume. RESULTS: The highest-volume surgeons (group D) performed the greatest proportion of total thyroidectomies among the 5860 discharges, and they were more likely to operate on patients with cancer. After adjusting for case mix and hospital volume, highest-volume surgeons had the shortest length of stay (1.4 days vs. 1.7 days for groups B and C and 1.9 days for group A) and the lowest complication rate (5.1 % vs. 6.1% for groups B and C and 8.6% for group A). Length of stay and complications were more determined by surgeon experience than hospital volume, which had no consistent association with outcomes. CONCLUSIONS: Individual surgeon experience is significantly associated with complication rates and length of stay for thyroidectomy.

Importance of hospital volume in the overall management of pancreatic cancer.

OBJECTIVE: To determine whether hospital volume is associated with clinical and economic outcomes for patients with pancreatic cancer who underwent pancreatic resection, palliative bypass, or endoscopic or percutaneous stent procedures in Maryland between 1990 and 1995. SUMMARY BACKGROUND DATA: Previous studies have demonstrated that outcomes for patients undergoing a Whipple procedure improve with higher surgical volume, but only 20% to 35% of patients with pancreatic cancer qualify for curative resection. Most patients undergo palliative procedures instead with a surgical bypass or biliary stent. METHODS: Analysis of hospital discharge data from all nonfederal acute care hospitals in Maryland identified all patients with pancreatic cancer who underwent a pancreatic resection, palliative bypass, or stent procedure between 1990 and 1995. Hospitals (n = 48) were categorized as high-, medium-, and low-volume providers according to their average annual volume of these procedures. Multivariate regression was used to examine the association between hospital volume and in-hospital mortality rate, length of stay, and hospital charges, after adjusting for differences in case mix and surgeon volume. RESULTS: Increased hospital volume is associated with markedly decreased in-hospital mortality rates and a decreased or similar length of stay for all three types of procedures and with decreased or similar hospital charges for resections and stents. After adjustment for case mix differences, the relative risk (RR) of in-hospital death after pancreatic resection was 19.3 and 8 at the low- and medium-volume hospitals, respectively, versus the high-volume hospital; after bypasses, the RR of death was 2.7 and 1.9, respectively; and after stents, the RR was 4.3 and 4.8, respectively. CONCLUSIONS: Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.

Profile of a clinical practice: Thresholds for surgery and surgical outcomes for patients with primary hyperparathyroidism: a national survey of endocrine surgeons.

A 1991 NIH Consensus Development Conference statement provided recommendations for the management of patients with asymptomatic and minimally symptomatic primary hyperparathyroidism (primary HPT), but adherence to these guidelines has not been documented. We conducted a cross-sectional survey of North American members of the American Association of Endocrine Surgeons inquiring about surgeon and primary HPT patient characteristics, thresholds for surgery, and clinical outcomes. Multivariate regression was used to assess the relationship of physician characteristics to practice patterns and outcomes. Of 190 surgeons surveyed, 147 (77%) responded; 109 provided complete responses (57%). These surgeons spend 66% of their time in patient care and perform an average of 33 (range, 1-130) parathyroidectomies/yr. More than 72% of primary HPT patients who underwent surgery were asymptomatic or minimally symptomatic. High volume surgeons (>50 cases/yr) had significantly lower thresholds for surgery with respect to abnormalities in preoperative creatinine clearance, bone densitometry changes, and levels of intact PTH and urinary calcium compared to their low volume colleagues (1-15 cases/yr). Overall reported surgical cure rates were 95.2% after primary operation and 82.7% after reoperation. Compared to high volume surgeons, low volume endocrine surgeons had significantly higher complication rates after primary operation (1.9% vs. 1.0% respectively; P < 0.01) and reoperation (3.8% vs. 1.5%; P < 0.001) as well as higher in-hospital mortality rates (1.0% vs. 0.04%; P < 0.05). Endocrine surgeons operate on a large number of asymptomatic or minimally symptomatic primary HPT patients. Even among a group of highly experienced surgeons who typically see patients after referral from endocrinologists, clinical outcomes and criteria for surgery vary widely and appear to be associated with surgeon experience. Their criteria for surgery diverge from NIH guidelines. These results implore the endocrine community to examine the evidential basis for decisions made in the management of primary HPT.

Association between extent of axillary lymph node dissection and survival in patients with stage I breast cancer.

BACKGROUND: The role of axillary lymph node dissection for stage I (T1N0) breast cancer remains controversial because patients can receive adjuvant chemotherapy regardless of their nodal status and because its therapeutic benefit is in question. The purpose of this study was to determine whether extent of axillary dissection in patients with T1N0 disease is associated with survival. METHODS: Data from 464 patients with T1N0 breast cancer who underwent axillary dissection from 1973 to 1994 were examined retrospectively. Kaplan-Meier estimates of overall survival, disease-free survival, and recurrence were calculated for patients according to the number of lymph nodes removed (<10 or > or = 10; <15 or > or = 15), and survival curves compared using the Wilcoxon-Gehan statistic. Cox proportional hazards regression modelling was used to adjust for confounding prognostic variables. RESULTS: Median follow-up time was 6.4 years. Patient groups were similar in age, menopausal status, tumor size, hormonal receptor status, type of surgery, and adjuvant therapy. There was a statistically significant improvement in disease-free survival in the > or = 10 versus <10 nodal groups (P <.01). Five-year estimates of survival were 75.7% and 86.2% for <10 nodes and > or = 10 nodes, respectively; 10-year estimates were 66.1% and 74.3%. There also was a notable improvement in the survival comparison of patients with <15 versus > or = 15 nodes (P < or = .05). These findings were confirmed in the multivariate analysis. CONCLUSIONS: These results may reflect a potential for misclassification of tumor stage among patients who had fewer nodes removed. The data, however, suggest that in patients with Stage I breast cancer, improved survival is associated with a more complete axillary lymph node dissection.

Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the Coronary Artery Surgery Study (CASS). CASS Participating Investigators and Staff.

OBJECTIVES: The Coronary Artery Surgery Study (CASS) required participants to undergo follow-up angiography at 5 years to identify clinical and angiographic features associated with progression of coronary artery disease. BACKGROUND: The CASS randomized 780 patients at 11 participating clinical centers between an initial strategy of medical therapy versus bypass surgery. Five clinical sites accomplished follow-up angiography in > 50% of their randomized subjects within a 42- to 66-month period after the entry arteriogram (n = 314). METHODS: Qualified clinical site angiographers, using side by side film review, evaluated an average of 13 segments/patient on both arteriograms for initial stenosis severity, morphologic features, lesion location and occurrence of disease progression or occlusion. Progression was defined as further definite narrowing by > or = 15% and occlusion as lesion progression to > or = 98%. Lesions were subcategorized as to whether they were univariate and had or had not been treated with bypass surgery. Multivariate logistic regression analyses were performed. RESULTS: For nonbypassed segments, right coronary artery and left anterior descending artery proximal and midlocations were associated with disease progression. For stenosis-containing segments, the initial severity, a non-left anterior descending artery location and increased treadmill duration predicted progression. Segment occlusion was associated with initial lesion severity, right coronary artery location and subsequent interval myocardial infarction. There were few predictors of progression or occlusion in bypassed arteries, other than initial lesion severity. CONCLUSIONS: Univariate and multivariate associations with lesion progression and occlusion included diabetes, lesion location, elevated cholesterol level, interval infarction and lesion morphology. These angiographic results, collected in a prospective trial, are consistent with known risk factors.

Prospective study of feasibility of routine use of multiple internal mammary artery anastomoses.

A study of 100 consecutive patients requiring multiple coronary artery bypasses was undertaken to evaluate the feasibility of routine use of multiple internal mammary artery (IMA) anastomoses. In 99 patients the IMA was used and in 80 patients bilateral IMA bypasses were done. In 15 patients multiple anastomoses with a single IMA precluded the need for bilateral IMA bypasses. In only 4 patients were bilateral IMA left to be contraindicated. By combination of use of both IMAs, free grafts and sequential grafts, the IMA accounted for 70% of the 318 anastomoses in these 100 patients. Scrupulous attention to technique and the use of the operating microscope are necessary to achieve multiple IMA anastomoses. It was concluded that the IMA can be used to supply the majority of anastomoses needed for coronary artery revascularization in nearly all patients.