A postoperative parathyroid hormone-based algorithm to reduce symptomatic hypocalcemia following completion/total thyroidectomy: A retrospective analysis of 591 patients.

BACKGROUND: An institutional protocol for selective calcium/calcitriol supplementation after completion/total thyroidectomy was established based on the 4-hour postoperative parathyroid hormone level. The aim of this study was to evaluate the outcomes of this protocol 5 years after implementation. METHODS: All patients who underwent completion/total thyroidectomy from January 2012 to December 2016 were reviewed. Predictors of a 4-hour parathyroid hormone level <10 pg/mL and symptomatic hypocalcemia were assessed. RESULTS: Of 591 patients, 448 (76%) had a 4-hour parathyroid hormone ≥10, 72 (12%) had a 4-hour parathyroid hormone of 5-10, and 71 (12%) had a 4-hour parathyroid hormone <5. Hypocalcemic symptoms were infrequent (30/448, 7%) if the 4-hour parathyroid hormone was ≥10; 56% (40/71) of those with a 4-hour parathyroid hormone <5 reported symptoms. With 4-hour parathyroid hormone of 5-10, symptoms were reported in 32 of 72 (44%) patients; supplementation at discharge included calcium (n = 55, 76%), calcium and calcitriol (n = 12, 17%), or none (n = 5, 7%). Ten patients subsequently received calcitriol for persistent symptoms. On multivariate analysis, predictors of 4-hour parathyroid hormone <10 included incidental parathyroidectomy, malignancy, and thyroiditis; predictors of hypocalcemic symptoms included age <55 and 4-hour parathyroid hormone <10. CONCLUSION: After completion/total thyroidectomy, patients with a 4-hour parathyroid hormone ≥10 can be safely discharged without routine supplementation. The addition of calcitriol to calcium supplementation should be strongly considered for patients with a 4-hour parathyroid hormone of 5-10.

Diagnosis and treatment of lymphedema after breast cancer: a population-based study.

OBJECTIVE: To examine factors associated with variations in diagnosis and rehabilitation treatments received by women with self-reported lymphedema resulting from breast cancer care. DESIGN: A large, population-based, prospective longitudinal telephone survey. SETTING: California, Florida, Illinois, and New York. PARTICIPANTS: Elderly (65+ years) women identified from Medicare claims as having had an incident breast cancer surgery in 2003. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported incidence of lymphedema symptoms, formal diagnosis of lymphedema, treatments for lymphedema. RESULTS: Of the 450 breast cancer survivors with lymphedema who participated in the study, 290 (64.4%) were formally diagnosed with the condition by a physician. An additional 160 (35.6%) reported symptoms consistent with lymphedema (ie, arm swelling on the side of surgery that is absent on the contralateral arm) but were not formally diagnosed. Of those who reported being diagnosed by a physician, 39 (13.4%) received complete decongestive therapy that included multiple components of treatment (ie, manual lymphatic drainage, bandaging with short stretch bandages, the use of compression sleeves, skin care, and remedial exercises); 24 (8.3%) were treated with manual lymphatic drainage only; 162 (55.9%) used bandages, compression garments, or a pneumatic pump only; 8 (2.8%) relied solely on skin care or exercise to relieve symptoms; and 65 (22.4%) received no treatment at all. Multivariate regressions revealed that race (African American), lower income, and lower levels of social support increased a woman's probability of having undiagnosed lymphedema. Even when they were formally diagnosed, African American women were more likely to receive no treatment or to be treated with bandages/compression only rather than to receive the multimodality, complete decongestive therapy. CONCLUSIONS: Lymphedema is a disabling chronic condition related to breast cancer treatment. Our results suggest that a substantial proportion of persons reporting symptoms were not formally diagnosed with the condition, thereby reducing their opportunity for treatment. The variation in rehabilitation treatments received by women who were formally diagnosed with the condition by a physician suggests that lymphedema might not have been optimally addressed in many cases despite the availability of effective interventions.

Persistent elevation in serum parathyroid hormone levels in normocalcemic patients after parathyroidectomy: does it matter?

BACKGROUND: The clinical importance of elevated serum parathyroid hormone (PTH) levels in patients with normocalcemia after curative parathyroidectomy (PTX) for primary hyperparathyroidism (pHPT) is unclear. This study sought to determine whether these patients, when compared with those with normal PTH levels, differ in preoperative and pathologic factors and are at increased risk of recurrent pHPT. METHODS: A chart review was performed of sporadic pHPT patients who underwent PTX between December 1999 and July 2011. RESULTS: Of 1,037 patients who underwent PTX, 310 had 6-month serum calcium, vitamin D, and PTH levels evaluated. PTX was curative (normocalcemia at ≥6 months) in 97%. At 6 months, 62 (21%) had elevated serum PTH levels. Compared with patients with normal postoperative PTH levels, patients with elevated PTH levels had greater BMI (P < .0001), greater PTH levels (P < .0001), and lesser vitamin D levels (P = .014) preoperatively and lesser vitamin D levels at 6 months (P = .05). At ≥1 year follow-up, 38 (61%) patients had calcium levels checked; all remained normocalcemic. PTH levels were available for 32 patients; 17 had persistently increased PTH levels. CONCLUSION: Patients with elevated PTH levels after curative PTX do not have greater rates of recurrence than patients with normal PTH levels. The greater PTH levels and lesser vitamin D levels support postoperative vitamin D supplementation in these patients.

Predicting the need for calcium and calcitriol supplementation after total thyroidectomy: results of a prospective, randomized study.

BACKGROUND: The optimal protocol for the detection and treatment of postthyroidectomy hypoparathyroidism is unknown. We sought to identify and treat patients at risk for symptomatic hypocalcemia on the basis of a single parathyroid hormone (PTH) obtained the morning after surgery (POD1). METHODS: We performed a prospective, randomized study of total thyroidectomy patients who had POD1 calcium and PTH (pg/mL) levels. Randomization was determined by POD1 PTH: if ≥ 10, patients received no supplementation unless symptomatic; if <10, patients were randomized to calcium, calcium and calcitriol, or no supplementation. RESULTS: Of 143 patients, 112 (78%) had a POD1 PTH ≥ 10. Hypocalcemic symptoms were transiently reported in 11 (10%) and managed with outpatient calcium. Of 31 patients with PTH <10, 15 (48%) developed symptoms, including 5 who required intravenous calcium. On multivariate logistic regression analysis, when we adjusted for postoperative calcium level and performance of central neck dissection, we found that predictors of hypocalcemic symptoms were younger age (odds ratio 1.59, 95% confidence interval 1.07-2.32) and a PTH <10 (odds ratio 1.08, 95% confidence interval 1.04-1.12). There were no patient or treatment-related factors that predicted a POD1 PTH <10. CONCLUSION: A single POD1 PTH level <10 can accurately identify those patients at risk for clinically significant hypocalcemia. All total thyroidectomy patients with a postoperative PTH ≥ 10 can be safely discharged without supplementation. Given the small number of patients with PTH <10, it is unclear whether both calcium and calcitriol are needed for these higher-risk patients.

The value of postoperative parathyroid hormone levels in predicting the need for long-term vitamin D supplementation after total thyroidectomy.

BACKGROUND: Few studies have examined the need for vitamin D supplementation after total thyroidectomy. This study examines the role of postoperative day (POD) 1 serum calcium and parathyroid hormone (PTH) levels in predicting the need for long-term vitamin D supplementation after total thyroidectomy. METHODS: A retrospective, single institutional study of patients who underwent total thyroidectomy between January 2007 and December 2008 was performed. Data collected included extent of surgery, final pathology, postoperative calcium (mg/dl) and PTH (pg/ml) values, and duration of vitamin D supplementation. Patients were divided into 4 groups based on POD1 PTH values: group 1 (<5.0); group 2 (5.0-10); group 3 (10.1-20); and group 4 (>20). RESULTS: Of the 104 patients, 26 were in group 1, 12 in group 2, 18 in group 3, and 48 in group 4, with median PTH values of <2.5, 8.2, 14.1, and 30 pg/ml, respectively. All 7 (7%) patients who required vitamin D supplementation >1 month were in group 1. The positive predictive value of POD1 PTH <5.0 in predicting supplementation >1 month was 27% (sensitivity 100%, specificity 80%). Seventy-eight patients had a POD1 PTH level ≥5, and none required vitamin D supplementation >1 month (100% negative predictive value). The positive predictive value of various POD1 calcium thresholds (<7.5, <8.0, and <8.5 mg/dl) was 17, 14, and 15%, respectively. CONCLUSIONS: Postoperative PTH levels better predict long-term hypocalcemia requiring vitamin D supplementation than serum calcium levels. A PTH level ≥5.0 may identify patients who can be safely discharged without routine vitamin D supplementation.

Subtotal parathyroidectomy for primary hyperparathyroidism.

OBJECTIVE: To discuss the etiology of multiple gland disease in the context of primary hyperparathyroidism, as well as indications for surgery, operative management and technical considerations of subtotal parathyroidectomy, and postoperative/long-term management. METHODS: We conducted a systematic review of the literature using evidence-based criteria. RESULTS: Approximately 15% of patients with primary hyperparathyroidism have multiple gland disease, and a small subset of these cases is due to a familial syndrome. Subtotal parathyroidectomy is one operative approach to the management of multiple gland disease. Subtotal parathyroidectomy for multiple gland disease results in normocalcemia in at least 95% of cases. Intraoperative parathyroid hormone monitoring can help guide the extent of the operation and determine the need to perform a concurrent autograft. After subtotal parathyroidectomy, most patients develop postoperative hypocalcemia and require calcium and possibly calcitriol supplementation; approximately 10% to 15% develop permanent hypoparathyroidism. All patients after parathyroidectomy, especially those with familial primary hyperparathyroidism, should undergo long-term follow-up for surveillance of recurrent primary hyperparathyroidism. If persistent or recurrent primary hyperparathyroidism occurs after subtotal parathyroidectomy, completion total parathyroidectomy and parathyroid autotransplant should be performed. CONCLUSIONS: Subtotal parathyroidectomy is an excellent surgical approach for patients with primary hyperparathyroidism due to multiple gland disease from either sporadic or familial causes.

Impact of randomized clinical trial results in the national comprehensive cancer network on the use of tamoxifen after breast surgery for ductal carcinoma in situ.

PURPOSE: The National Surgical Adjuvant Breast and Bowel Project B-24 trial, published in June 1999, demonstrated that tamoxifen after breast-conserving surgery (BCS) and radiotherapy for ductal carcinoma in situ (DCIS) reduced the absolute occurrence of ipsilateral and contralateral breast cancer. We assessed the impact of B-24 on practice patterns at selected National Comprehensive Cancer Network (NCCN) centers. PATIENTS AND METHODS: Tamoxifen use after surgery was examined among 1,622 patients presenting for treatment of unilateral DCIS between July 1997 and December 2003 at eight NCCN centers. Associations of clinicopathologic and treatment factors with tamoxifen use were assessed in univariate and multivariable logistic regression analyses. RESULTS: Overall, 41% of patients (665 of 1,622) received tamoxifen. The proportion increased from 24% before July 1, 1999, to 46% on or after July 1, 1999. Factors significantly associated with receipt of tamoxifen included diagnosis on or after July 1, 1999 (odds ratio [OR], 3.85; P < .0001), BCS in patients younger than 70 years (OR, 3.21; P = .0073), no history of cerebrovascular or peripheral vascular disease (OR, 3.13; P = .0071), receipt of radiotherapy (OR, 1.82; P = .0009), and previous hysterectomy (OR, 1.34; P = .0459). Tamoxifen use varied significantly by center, from 34% to 74% after BCS and 17% to 53% after mastectomy (P < .0001). CONCLUSION: Tamoxifen use after surgery for DCIS at NCCN centers increased after presentation of the B-24 results. Rates varied substantially by institution, suggesting that physicians differ in how they weigh the modest reduction in breast cancer risk with tamoxifen against its potential adverse effects in this population.

Physician recommendations regarding tamoxifen and patient utilization of tamoxifen after surgery for ductal carcinoma in situ.

BACKGROUND: To date, the impact of the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-24 trial reported in 1999 on the use of tamoxifen after surgery for ductal carcinoma in situ (DCIS) is unknown. The current study was designed to evaluate the impact of NSABP B-24 on current practices at a comprehensive cancer center. METHODS: The records of 350 consecutive patients with DCIS who were treated at the authors' institution between July 1999 and June 2002 were obtained from a prospective database and analyzed. Whether patients were offered tamoxifen, whether patients accepted tamoxifen, and the associated reasons were recorded along with tamoxifen-related side effects and patient compliance with therapy. Clinical and pathologic factors were evaluated for their impact on recommendations regarding tamoxifen. Differences were assessed by chi-square analysis. RESULTS: Of the 350 patients, 73 were excluded because of evidence of invasive carcinoma on final pathology review. Of the remaining 277 patients, 166 patients (60%) were offered tamoxifen, and 90 patients (54%) chose to take tamoxifen. Of 111 patients who were not offered tamoxifen, 39 patients (35%) had documented explanations, which included bilateral mastectomy (n = 25 patients), medical reasons (n = 10 patients), and already received tamoxifen for other reasons at the time of diagnosis (n = 4 patients). Of 94 patients who received tamoxifen, 20 patients (21%) discontinued use because of side effects or complications. Tamoxifen was more likely to be recommended for women who underwent segmental resection compared with women who underwent total mastectomy (P = 0.002) and for women with smaller pathologic DCIS tumors (P = 0.001). In addition, these two factors were interrelated. CONCLUSIONS: Physicians and patients remain cautious regarding the use of tamoxifen after local treatment for DCIS. The current findings have implications for current trials evaluating aromatase inhibitors and other chemopreventive agents for this disease.