Predicting distant metastatic disease in differentiated thyroid cancer: a matched case-control study.

BACKGROUND: The occurrence of distant metastasis (DM) is the most important prognostic factor influencing survival outcomes in differentiated thyroid cancer (DTC). Identifying patients who are likely to develop DM and offering these cases more aggressive surgical approaches and I-131 therapy, is paramount to achieving the best possible outcomes. DM on presentation in DTC are uncommon, with an incidence of 1-9%. However, the incidence of DTC is rising and the disease affects a relatively young cohort of patients. The aims of this study were to investigate predictive factors in the development of DM by comparing a homogenous group of DTC patients with and without DM, and to illustrate the overall and disease-specific survival (DSS) rates of DTC patients presenting with DM. METHODS: A matched case-control study of patients with DTC and DM was undertaken. The study group comprised a consecutive series of cases with DM treated in the period 1968-2014. Patients with DM at initial presentation were identified (DTC-DM group). A control group of patients without DM were matched based on age, gender, tumour size and histological subtype. The primary outcome measures were overall and disease-free survival. Secondary outcome measures were lymph node involvement (LNI), extra-thyroidal extension (ETE) of tumour and presence of BRAFV600E mutation identified on immunohistochemistry. RESULTS: A total of 2547 patients with DTC were reviewed and of these 83 (3.26%) had DM at initial presentation. At 5 and 10 years, the overall survival rates for DTC-DM patients were 89.6% and 64%, respectively. The 5 and 10 year DSS rates for DTC-DM cases were 90.2% and 67.3%, respectively. When compared to the DTC group, the DTC-DM group had significantly higher rates of ETE (63% vs. 29.5%, P < 0.0001) and LNI (32.5% vs. 18.8%, P = 0.044). Among patients with papillary thyroid cancer (PTC), the presence of BRAFV600E mutation was significantly associated with DM (62.2% vs. 36.8%, P = 0.028). CONCLUSION: ETE, LNI and BRAFV600E mutation in PTC are significant predictors for the development of distant metastatic disease.

Characterization of Self-Reported Dysphagia and Impact on Weight Outcomes After Laparoscopic Sleeve Gastrectomy.

INTRODUCTION/AIMS: There is paucity of literature examining dysphagia after laparoscopic sleeve gastrectomy (LSG). Moreover, there are few validated scoring systems for dysphagia that adequately assess its psychosocial impact. We aim to investigate dysphagia after LSG using a multidimensional scale that examines its functional and emotional impact. As secondary aims, we evaluated the impact of dysphagia on weight outcomes and its relationship with pre-operative gastro-esophageal reflux disease (GERD) and proton pump inhibitor (PPI) use. METHODS: One hundred twenty-four patients 1 year or more post-LSG were administered the validated Dysphagia Handicap Index (DHI) questionnaire. To further delineate esophageal dysphagia, three additional questions were added. One hundred one patients (81.5%) responded. Physical, Emotional, Functional, and Esophageal scales were analyzed combined and individually using a multivariate model. RESULTS: No patients reported dysphagia pre-operatively. The median DHI scale scores are the following: Physical-2 (0-20); Functional-4 (0-22); Emotional-2 (0-14); and Esophageal-2 (0-8). On multivariate analysis, DHI Emotional scores significantly correlated with reduced total weight loss (%TWL) (p = 0.001) and excess weight loss (%EWL) (p = 0.023). The physical symptoms of dysphagia did not affect weight outcomes. Post-operatively, PPI usage increased significantly (15.8 vs 19.8%, p = 0.01) and correlated with higher dysphagia scores. CONCLUSION: A statistically validated dysphagia-specific questionnaire was utilized to evaluate the impact of LSG on dysphagia including its functional and emotional influences. The psychosocial handicap of dysphagia significantly reduced weight loss outcomes. A correlation between PPI use and dysphagia after LSG was found. The prevalence of dysphagia after LSG and the factors that contribute to its symptoms need to be further studied.